Park's Textbook of

PREVENTVE
AND SOCIAL
MEDICINE

K. PARK

***
(50 *** **
70-202
(26
ED
EANCT T1O
 CONTENTS
Page
Chapter

MAN AND MEDICINE TOWARDS HEALTH FOR ALL

* 13
2. CONCEPT OF HEALTH AND DISEASE
60
3. PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS
Infectious disease epidemiology. *********
100
Aims of Epidemiclogy
Epidemiological approach... Disease transmission. 102
. Immunity .109
Measurement of mortality .111
Rates and ratios 65 immunising agents ** ******* ********* **********

Cold chain ****** ***** ** ************" .117

Measurement of morbidity *********
..
Epidemiclogic methods.. 70 Open Vial Pblicy I20
Adverse events after immunization. 122
Descriptive epidemiclogy.
Disease prevention and control..... 130
Analytical epidemiologs
Cohert study . Immunication schedule .. 134
Experimenta epidemiology. SS Disinfection.. 139
Investigation of an epidemic .146
Association and causation... 95
Uses of epidemiology ***** 99
150
SCREENING FOR DISEASE
4.
Coneept of screening.. 150 Sensitivity and speciñicity
..
Uses of screening. 151 Problems of the borderline ...
Criteria for screening.
EPIDEMIOLOGY OF COMMUNICABLE DISEASES *** *** 15S

I. Respiratory infections
Smallpox. 158 Whooping cough
.. ** 79
Chickenpox . 158 Meningococcal meningitis. 181
Measles 161 Acute respiratory iniections 183
SARS. 190
Rubella
Mumps ******** n Ib8
5

COVID-19 . 192
Influenza. 169 Tuberculosis 204
Diphtheria 175

I. Intestinal infections
Poliomyelitis ********* 236 Food poisoning.
**************************************** 276
Viral hepatitis 244 Amoebiasis. *278S
Acute diarrhoeal diseases. 258 Ascariasis
Cholera
Typhoid fever . 272
l.
266 Hookworm infection
Dracunculiasis..

Arthropod-borne infections
281
283

Dengue syndrome.
HiEaastaoaisdasiss 284 Lymphatic Filariasis... ..310
Malaria i 294 Zika Virus Disease. 16
IV Zoonoses
Viral Bacterial
Rabies. 317 Chikungunya fever .
Yellow fever 322 Brucellosis.
332
Nipah virus infection ** dZ5, Leptospirosis ..
Japanese encephalitis 26
KFD Human saimonellosis ....
334
330 ***********+tsasA++a 40)
 Porasitic z0ottose2s
Taeniasis
Rirkettsidl diseases .345
Hydatid disease. v*d************** **vii
341
Ricketsinl ztoconoses Leishmaniasís 346
Scrub tvphus ..... 342
342
Musine lyphus
Tick typhus 343
V. Surface infections **************************************veus 374
STDosnee ******v************************oiz 35
351 niiietivrë*
Trachorma.. i.disssatecas .37
353
Telanus 1444aniiiintes**i
,

357
AIDS o
diseases 400
Leprosy.
Emerging and
re-emerging infectious
VI. 404
VII. Hospital
acqufred Infections
* **** 407
NON-COMMUNICABLE ******

EPIDEMIOLOGY OF CHRONIC
6.
DISEASES AND CONDITIONS ****************************************** 438
Cardiovascular diseases..
. 411 Diabetes. r*
43
Obesity
412
Coronary heart disease... Blindness.. *********************w************-***v,

Hypertension.. 419
.ausnasan Oral diseases..

Rheumatic hearl disease

.. .. 425
427
Accidents and Injuries.. ***************w******

Cancer. ***********is******
**** 464
7. HEALTH PROGRAMMES IN INDIA ***** 540
cOUNTERFEIT MEDICINES
****
***

8. ESSENTIAL MEDICINES AND ***** 552

***

MILLENNIUM DEVELOPMENT GOALS TO

9 SUSTAINABLE DEVELOPMENT GOALS
********* ** 560
10. DEMOGRAPHY AND FAMILY PLANNING
602
PREVENTIVE MEDICINE IN OBSTETRICS,
********

11.
PAEDIATRICS AND GERIATRICS
.4
698
NUTRITION AND HEALTH
********

12.
158
MEDICINE AND SOCIAL SCIENCES
*****

13.
795
14. TRIBAL HEALTH IN INDIA
79
15. ENVIRONMENT AND HEALTH **
***

833
16. HOSPITAL WASTE MANAGEMENT *** **

17. DISASTER MANAGEMENT

88
89E
18. ocCUPATIONAL HEALTH
915
19. GENETICS AND HEALTH ******

925
20. MENTAL, HEALTH
93-
21. HEALTH INFORMATION AND BASIC MEDICAL STATISTICCS *** ***

22 COMMUNICATION FOR HEALTH EDUCATION +**

95

23. HEALTH PLANNING AND MANAGEMENT ***

96
***

24. HEALTH CARE OF THE COMMUNITY 98

***

25. INTERNATIONAL HEALTH 101

ABBREVIATIONS
10
INDEX
 AND DISEASE which
CONCEPT OF HEALTH weighted composite index,outco
32 The health index is a domains (a) Health
:
comes
is
(68) indicators in three
5. Health Index of
India (Niti Aayog) UTs in
based on
Governance and information (12 perdoma
co
ranked all states and
recently (70 per cent); (b} processes (18 per cent). Each
Niti Aayog of India performance. The and (c) Key inputs and domain
the nations health on its importance. Within a
an attempt to measure categories to ensure is assigned a weight based distribute
UTs are grouped in three states, weight has been equally
states and entities namely 21 larger or sub-domain, the heals
comparisons among similar Territories as shown in Table 5. among the indicators. Table 6 provides the detailed
7 Union definitions, the data sources and
8 smaller states and index with indicators, their year (RY) (68).
reference
TABLE 5 specifics of base year (BY) and
Categorization of states and UTs REGIONS
DEVELOPED AND DEVELOPING
Number divided into developed and
of States States and UTs The world today is some common features
Category
and UTs developing regions on the basis of
represented by countries such
shared by them. The former is by countries such as India. If
Andhra Pradesh, Assam, Bihar, Himachal
Larger 21
Chhattisgarh, Gujarat, Haryana, as USA and UK, and the latter organization of society to
states
Pradesh, Jammu & Kashmir, Jharkhand, one defined development as the health services, education
Karnataka, Kerala, Madhya Pradesh, provide adequate housing, food, of people, then many
Maharashtra, Odisha, Punjab, Rajasthan, and employment for the majority mark. Social medicine
Tamil Nadu, Telangana, Uttar Pradesh, developing countries are wid of the among countries. This
Uttarakhand, West Bengal
is concerned with disparities that
exist
Arunachal Pradesh, Goa, Manipur,Sikkim, is because socio-economic factors and health problems are
Smaller Meghalaya, Mizoram, Nagaland, is given below
states interlinked. An account of these disparities
Tripura

Union Andaman & Nicobar, Chandigarh, Dadra 1. Social and economic characteristics
& Nagar Haveli, Daman & Diu, Delhi, live in rural areas
Territories
Lakshadweep, Puducherry Most people in the developing countries

TABLE 6
reference years
Health Index Indicators, definitions, base and
:
Base Year (BY)
& Reference
S.No. Indicator Definition Year (RY)

-
DOMAIN1 HEALTH OUTCOMES
Sub-domain 1.1 - Key outcomes (Weight: larger states 500, smaller states & UTs-100)
-

thousand live births BY:2015

Neonatal mortality Number of infant deaths of less than 29 days per RY: 2016
1.1.1 during a specific year.
rate (NMR)
live births BY: 2015
1.1.2 Under-five mortality Number of child deaths of less than 5 years per thousand RY : 2016
rate (U5MR) during a specific year.

Average number of children that would be born to a woman she

if experiences BY:2015
1.1.3 Total fertility reproductive span (15-49 years), RY: 2016
rate (TFR) the current fertility pattern throughout her
during a specific year.
BY: 2015-16
Proportion of low birth weight (2.5 kg) newborns out of the total number
of
1.1.4 Proportion of low birth a public health facility. RY: 2017-18
weight (LBW) among newborns weighed during a specific year born in
newborns
The number of girls born for every 1,000 boys born during a specific year.
BY:2012-15
1.1.5 Sex ratio at birth (SRB)
RY:2014-16
Sub-domain 1.2 Intermediate outcomes (Weight: larger & smaller states -300, UTs-250)
-

1.2.1 Full immunization Proportion of infants 9-11 months old who have received BCG, 3 doses BY:2015-18
coveragee of DPT, 3 doses of OPV and one dose of measles against estimated number RY: 2017-18
of infants during a specific year.

1.2.2 Proportion of Proportion of deliveries conducted in public and private health facilities BY: 2015-16
institutional deliveries against the number of estimated deliveries during a specific year. RY:2017-18
1.2.3 Total case notification Number of new and relapsed TB cases notified (public + private) By: 2016
rate of tuberculosis (TB) per 100,000 population during a specific year. RY: 2017
1.2.4 Treatment success rate Proportion of new cured and their treatment completed against the total BY:2015
of new microbiologically number of new microbiologically confirmed TB cases registered RY: 2016
confirmed TB cases during a specific year.

1.2.5 Proportion of people Proportion of PLHIVs receiving ART treatment against the number of BY:2015-16
living with HIV (PLHIV) estimated PLHIVs who needed ART treatment for the specific year. RY: 2017-18
onantiretroviral
therapy (ART)
 VETO/) AN DEUEIFING PEGON 33
Base Year (BY)
S.No. Indicator Definition & Reference
Year (RY}

DOMAIN2 GOVERNANCE AND INFORMATION

Sub-domiain 2,1 health monitoring and data integrity (Weight: 70)

2.1.1 Data Integrity Measure :

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

Sub-domain 2.2 Governance (Weight -60)

-

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

2.2.2 Average occupancy ofa Average occupancy of a CMO (in months) for all the districts BY April 1. 2013-
full-time officer (in months) in last three years. March 31. 2016
for all the districts in last
three years District Chief
-
RY April 1, 2015-
Medical Officers (CM0s) March 31, 2018
or equivalent post
(heading District Health
Services)

DOMAIN 3- KEY INPUTS/PROCESSES

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

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

3.1.2 Proportion of total staff Availability of a functional IT-enabled HRMIS measured by the proportion BY Ason
(regular + contractual) of staff (regular + contractual) for whom an e-payslip can be generated March 31, 2016
for whom an e-payslip in the IT- enabled HRMIS against total number of staff
can be generated in the (regular + contractual) during a specific year RY: As on
1IT-enabled Human March 3 L, 2018
Resources Management
System (HRMIS).

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

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

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

Proportion of pregnant women registered for ANC within

12 weeks of BY
315 Proportion of ANC 2015-16
registered within first pregnancy during a speciic year.
RY:
trimester against total 2017-18
registrations
4 CONCEPT OFHAL11 AND D1SEASE

Base Year
S.No. Indicator Deflinilion
(B
& Relerence
Year (RY)

3.1.6 Level of reglstration Proportion of births registered under Civil Registration System (CRS) BY 2014
of births ngainst the estimaled number of birihs during a specilic year. RY
2016

3.1.7 Completeness of IDSP Proportion of Reporting Units (RUs) reporting in stipulated time period 2015
reporting of P and L ioms against tolal RUs, for P and L forms during a specific year. Y 2017
BY:
3.18 Proportion of CHCs with Proportion of CHCs that are graded above 3 points against total number of 2015-16
grading above 3 points CHCs during a specific year RY:2017-18

3.1.9 Proportion of public health Proportion of specified type of public health facilities with accreditation BY: As on
facilities with accreditation certilicates by a standard quality assurance program against the total March 31, 2016
certificates by a slandard number following specified type of facilities during a specific year.
1. District hospital (DH)/Sub-district hospital (SDH) RY: Ason
quality as5surance program
(NQAS/NABH/ISO/AHPI) 2. CHC/Block PHC March 31.2018

Average time taken (in number of days) by the State Treasury to transfer BY: 2015-16
3.1.10 Average number of days
for transfer of Central funds to implemenlation agencies during a specific year.
NHM fund from State RY:2017-18
Treasury to implementation
agency (Department/Society)
based on all tranches of
the last financial year
Hilly and North.
Criteria for fully operational FRUs: SDHs/CHCs conducting minimum 60 C-sections per year (36 C-sections per year for
per year for Hilly and North-Eastern
Eastern States except for Assam); DHs- conducting minimum 120 C-sections per year (72 C-sections
States except Assam).
except Assam)
**
Criteria for functional 24x7 PHCs: 10 deliveries per month (5 deliveries per month for Hilly and North-Eastern States
flexi-pool data (representing a substantial
# Centre NHM Finance data includes the RCH flexi-pool and NHM-Health System Strengthening
portion of the NHM funds) for calculating delay in transfer of funds.

and urban slums. There is a rigid hierarchy and class population growth is slowing down almost everywhere
structure moulded by tradition and long-standing customs. except Africa. The tertility rate is now at or below
The family, often a joint family, is a strong binding force. replacement level in 44 per cent of countries in the world
High fertility has multiple consequences tor health
and
People depend mainly on agriculture and there is lack of
a
health related issues. Continued rapid population growth in

alternative employment opportunities. The GNP per capita higher

$ 2000 to 6000 in most developing low and lower-middle-income countries, along with
ranges from US
fertility rates in poorest segments ot the population makes
countrie5. The production and consumption per capita are and
is not fully harder to eradicate poverty, combat hunger access
low. They have an economic potential which in health and education, improve
natural resources malnutrition, invest
realized; this refers to unemployed labour, to basic services, plan and develop cities, protect
local
Science and technology are not fully
and fertility the soil.
of
ecosystems and promote peaceful societies (66).
of literacy is low it averages only 63 per
applied. The level -
billion.
of life is In mid-2017, the World Population reached 7.4
cent in the least developed countries. The quality n
poor because of the scarcity of essential goods, facilities and of which 60 per cent live in Asia. The population tne
by distance, poor developing countries is a "young population:
money. There is isolation caused year
communication and transport lacilities. The environment
is proportion of persons under 15 years of age in the
unfavourable predisposing to communicable diseases and 2016 was about 41 per cent in the least developed countries
to ab0u
malnutrition. The vast majority of people are not able to pay and 24 in other developing countries, as compared
of iree medical 16 per cent in the developed countries. The proportion
for medical services. There is long tradition
a
Is abou
services provided by the State. people over 65 years of age in developing countries
5 per cent, compared to 18 per cent in the develop
In the developed countries, most people (8 out
of 10) are ot tni
in the villages by countries (69). The social and economic backlashes
urban residents. Urban lile difers from that age distribution are being felt in both the developing d
economically employed.
being more impersonal. Women are developed countries the former
- having to bear the hedvy
of scientific
Agricullure is second to industry. Great use madelife
is you
of living and quality of are high. burden of providing for a population which is mainly
disciplines. The standard and the latter having to deal with the problems ageing
of
to 40,600 in most
The GNP per capita ranges from US 5000
$
universal.
developed countries. The adult literacy almost is
3. Contrasts in health (Health gap) even

2. Demographic characteristics While accurate statistical data are difficult to obtainl.

Demographic trends fundamentally influence country's
economic, social and health conditions. Population growth,
all have a
changes in fertility rates and population structure,
as do migration (which is increasingly a
profound infiuence,
cross-border issue) and growing urbanization which may
pertunctory glance at available data (Table 7) are sul the
to illustrate the wide healih gap between populato
developed and developing countries.
'a
Table 7 shows that the present gap in hne ntries
birth between developed and developing coed
by

spur economic growth but als0 put strain on food and water 15-20 years. Developed countries are C d mortall
resources. longer lite expectancy and lower infant and
chiia
cou ntries.
Fertility rates are falling globally and as a consequence, rates, and the opposite is true of developing
disability and handicap which are
CHANGING PATTERN OF DISEASE 51
later stages have large
ocial and environn nmental components tuberculosis, cardiac patients and others. The purpose of
dependence and social cost (95). in terms of
rehabilitation is to make productive people out of non-
productive people.
Disability prevention
It is now recognized that rehabilitation is a difficult and
Another concept is "disability
prevention". It relates to demanding task that seldom gives totally satisfactory results;
the levels of prevention: (a) reducing all
but needs enthusiastic cooperation from different segments
impairment, viz. immunization the occurrence of
of society as well as expertise, equipment and funds not
prevention); (b) disability limitation against polio (primary
by appropriate treatment readily available for this purpose even in affluent societies. It
(secondary prevention);
and,
disability into handicap (tertiary
(c) preventing the
transition of
is further recognized that
interventions at earlier stages are
prevention) (115). more feasible, will yield results, and are less demanding of
The major causes of disabling impairments Scarce resources.
countries are communicable diseases, in the developing
malnutrition, low quality CHANGING PATTERN OF DISEASE
of perinatal care and accidents. These are
responsible for about
70 per cent of cases of disability in Although diseases have not changed significantly through
developing countries.
Primary prevention is the most effective way human history, their patterns have. It is said that every
disability problem in developing
of dealing with the
countries (115). decade produces its own pattern of disease. The truth of this
will be obvious when one compares
5. Rehabilitation the leading causes of
death globally for the year 2000 and 2020 (118A).
Rehabilitation has been defined as
"the combined and
coordinated use of medical, social, YEAR 2000
vocational measures for training educational and
individual to the highest possible level
and retraining the Rank Cause Deaths % of total
of functional ability" (000s) deaths
(116). It includes all measures aimed
at reducing the impact 1. Ischaemic heart disease
of disabling and handicapping 7,029 13.4
conditions and at enabling 2. Stroke
the disabled and handicapped to achieve 5,170 9.9
(115). Social integration has
social integration 3. Lower respiratory infections 3,325
been defined as the active 4. 6.4
Chronic obstructive pulmonary 2,972
participation of disabled and handicapped 5.7
mainstream of community life (117).
people in the disease
5. Diarrhoeal diseases
It involves Rehabilitation
2,246 4.3
medicine or Physical medicine or 6. Tuberculosis 1,684
Physiatry has emerged in recent years 7 HIV/AIDS
3.2
It aims to
as a medical speciality. 1,469 .8
enhance and restore functional ability and quality of 8. Preterm birth complications
life to those with
1,382 2.6
physical impairments or disabilities. A 9. Trachea, bronchus, lung cancers 1,257 2.4
physiatrist specializes in restoring optional 10. Road injury
with injuries to the muscles,
function to people 11. Birth asphyxia and birth trauma
1,136s1E 2.2
bones, ligaments or nervous 1,125i 2.2
system. Six formal sub-specialization 12. Cirrhosis of the lever
are recognized are: 988 1.9
neuromuscular medicine, pain 13. Diabetes mellitus
medicine, paediatric 944 .8
rehabilitation medicine, spinal cord injury
medicine, sports 14 Alzheimer disease and other 804 1.5
medicine and brain medicine. Paramedical dementias
persons are involved and non-medical 15. Self-harm
in the discipline. They are physical 790 1.5
medicine or physiotherapy, occupational All causes
therapy, speech 52,307 100.0
therapy, audiology, psychology, education,
VOcational guidance and placement
social work,
services. The following YEAR 2020
areas of concern in
rehabilitation have been identified:
(a) Medical rehabilitation Rank Cause Deaaths % of total
-
restoration of function. (000s) deaths
(6) Vocational rehabilitation -
restoration of the capacity Ischaemic heart disease
to earn a livelihood. 8,138 16.59
2. Stroke
) Social rehabilitation 4,987 10.16
restoration of family and social 3. Chronic obstructive pulmonary
2,624
relationships. disease 5.34
d) Psychological rehabilitation restoration of personal Lower respiratory infections
(including 8,64,000 deaths caused
2,551 5.2
dignity and confidence.
by Covid-19 as of Sep. 2020)
Rehabilitation is no longer looked upon as an extra- Alzheimer disease and other
rricular activity of the physician. The current view is that dementias 1,718 3.5
responsibility of the doctor does not end when the 6. Trachea, bronchus, lung cancers 1,473
perature touches normal and stitches are removed 7 Diabetes mellitus
1,379
3.0
patient must be restored and retrained "to live and work
wEnin the limits of his disability
8 Road injury
1,210
2.81
2.47
but to the hilt of his 9 Diarrhoeal diseases 1 ,192
acty As such medical rehabilitation should start very 10. Tuberculosis 2.43
early in the process 1,115 2.27
of medical treatment. 11. Cirrhosis of the lever
1,081
12. Kidney diseases 2.21
amples of rehabilitation are: establishing schools tor 1,017 2.07
Surno provision of aids for the crippled, reconstructive 13 Preterm birth complications
Surgery in leprosy, HIVIAIDS 874 1.7
muscle re-education and 14
n neurological disorders, 872 1.78
hange of profession for
15. Hypertensive heart disease
for a more 774 1.58
ble one and modificat
of life in general the case of
in All causes
60,791 100.0
56 CONCEPT OF HEALTIH AND DISEASE
the community, with special attention to vulnerable groups.
The functions of the health centre are discussed elsewhere.
The functions of a doctor (physiclan) may be summarized as
follows:
(a) The care of the individual: A physician must be able to
assess the state of health of the individual. This would
include a clinical diagnosis, a simple laboratory diagnosis as
well as an assessment of the individual's state of nutrition,
level of development, social and emotional state and the
health needs. He must then be able to take any further
measures necessary for treatment, prevention and referral to
higher levels of health care. He must be particularly expert
in common conditions, in first-aid and in the management of
acute emergencies. Because of the large numbers involved,
he must know how to delegate work to his auxiliaries.
(b) The care of community: The care of the community
centres round the eight essential elements of primary health
care as stated in the Alma-Ata Declaration (see page 37)
The physician is the leader of the "health team". He
provides primary health care through the health team at the
grass-root level. He should be familiar with community
diagnosis, prioritization of health problems and community
treatment.
(c) The physician as a teacher: The term "doctor by
derivation means to teach. Therefore the physician has a
major responsibility as a teacher and educator. In his
practice, in his professional associations and in his
community activities, the physician has wide educational
opportunities. But unfortunately, the physician's role as a
teacher is a neglected one. Many physicians are reluctant to
capitalize on their role as educators. As a teacher, the
physician can play an effective role in community health
education so that individuals, families and communities
assume greater responsibility for their on health and
welfare, including self-care. He can also generate and
mobilize community participation in health programmes
through effective propagation of relevant information.
Community diagnosis
The diagnosis of disease in an individual patient is a
fundamental idea in medicine. It is based on signsand
symptoms and the making of inferences from them. When
this is applied to a community, it is known as community
diagnosis. Ihe community diagnosis may be deined as the
pattern of disease in a community described in terms of the
important factors which influence this pattern (137).
The community diagnosis is based on collection and
interpretation of the relevant data such as (a) the age and
sex distribution of a population; the distribution of
population by social groups; (b} vital statistical rates such as
the birth rate, and the death rate; (c) the incidence and
prevalence of the important diseases of the area. In
addition, a doctor must be able to find information on a
wide variety of social and economic factors that may assist
him in maing a community diagnosis. The focus is on the
identification of the basic health needs and health problems
of the community. The needs as felt by the community
(Some of which may have no connection at all with health)
should be next investigated and listed according to priority
for community treatment
Community treatment
Community treatment or community health action is the
sum of steps decided upon to meet the health needs of the
community taking into account the resources available and
the wishes of the people, as revealed by Com.
diagnosis. Improverment ot water supplies, immunni
health education, Control,O specitic diseases, h
legislation are examples of community health ac
interventions. Action may be taken at three levele
level of the individual, at the level of the family and
level of the community (137). atthe
A programme of community action must havo
following characteristics: (a) it must effectively utilize all
available resources, (b) it must coordinate the efforts of
other agencies in the community, now termed
"intersectoral coordination, and (c) it must encourage t
full participation of the community in
the programme. Thea
are the principles on which primary health care, as define
in the Alma-Ata Declaration, is based. This approach is a
significant departure from the earlier basic servin rvic%
approach.
DISEASE CLASSIFICATION
There is a wide variation among countries in the criteria
and standards adopted for diagnosis of diseases and thet
notification, making it difficult to compare national statistis
A system of classification was needed whereby diseases coul
be grouped according to certain common characteristics, tha:
would facilitate the statistical study of disease phenomera
Over the years, many approaches were tried to classi;
diseases. John Graunt in the 17th century in his study of Bil
of Mortality, arranged diseases in an alphabetical orde
Later, a more scientific approach was adopted in classiting
diseases according to certain characteristics of the disease c
injuries such as (a) the part of the body affected (6) te
aetiologic agent (c) the kind of morbid change produced ty
the disease, and (d) the kind of disturbance of funcicn
produced by the disease or injury. Thus there are many ax
of classification, and the particular axis selected will depent
on the interest of the investigator (138).
International classification of diseases
All the above criteria formed the basis of the Internation
classification of diseases (ICD) produced by WHO an
accepted in the year 1940 for national and international us
Since its inception, ICD has been revised about once ever
10 years; the 10th revision, came into effect on Januar
1993. Earlier, the scope of ICD was expanded in the
SI
revision in 1948 to cover morbidity from illness and injui
The ICD also provides a basis that can be adapted for
use
other fields.
ICD is the foundation for the identification ot hed
trends and statistics globally and is the internatiot is a
standard for reporting diseases and health conditions.
resea
diagnostic classification standard for all clinical and
purposes. ICD defines the universe of diseases, disoru
injuries and other related health conditions, listed
comprehensive, hierarchical fashion that allows to
storage, retrieval and analysis of health informatiou
evidence-based decision-making; sharing and compand
health information between hospitals, regions, sertrs
locatio
Countries; and data comparison in the same
different time period.
ICD-11 (139) ntury to
the 21st c ove
The ICD-11 has been updated for wilth
and me
retlect the significant progress in science ue w
years and has been designed for the
the past30
unity
DISEASE CLASSIFICATION 57
diaital health applications and application systems. The and connective
tion, 15. Diseases of the musculoskeletal system
ealth diaital platform for ll can be accessed online or tissue.
downloaded remotely free of charge and in multiple
or 16. Diseases of the genitourinary system.
the languages via the online browser. lt comprises over 55,000
entities. 17. Conditions related to sexual health.
the 18. Pregnancy, childbirth and the puerperium.
Besides diseases, ICD includes disorders, injuries,
externalcauses, signs and symptoms, substances, 19. Certain conditions originating in the perinatal and
the
medicaments, anatomy, devices, histopathology, severity neonatal period.
the and much more and l20,000 clinical terms (and can code
all 20. Developmental anomalies.
millions of terms), with thousands of new categories and Symptoms, signs or clinical findings, not elsewhere
as undated classification schemes, and is intended to supersede 21.
the the 10th Revision, which was more than 28 years old and
classified.
hese
clinically outdated. 22. Injury, poisoning or certain other consequences of
ined external causes.
is a New to 1CD-11 is a chapter on sexual health, which
23. External causes of morbidity and mortality.
ices brings together several conditions that were previously
classified differently. Gender incongruence is included in this 24. Factors influencing health status or contact with health
new chapter, reflecting an understanding that it is not a services.
mental health condition. Re-classification should help to 25. Codes for special purposes.
reduce the stigma attached to gender-defined states. 26. Supplementary chapter, Traditional Medicine
eria Another new chapter focuses on traditional medicine, Conditions -ModuleI.
heir commonly used across many countrie. In a landmark V. Supplementary section for functioning assessment.
tics. decision, stroke is now listed as a neurological disorder and
buld X. Extension codes.
not as a disorder of the circulatory system. This important
that change was long overdue and it brings stroke out of the
other classifications and
ena. shadow of heart disease. Linkageswith
Ssify terminologies (139)
The new classification of HIV recognizes advances in HIV
Bills The ICD-11 incorporates on links with the following
therapy, which should be seen as a chronic condition.
der. Allergy is coded under diseases of the immune system. classifications and terminologies through the ICD-11
Jing Attention deficit hyperactivity disorder's updated description foundation
2 or states that the symptoms no longer have to occur within a. International Classification of Disease for Oncology
the fixed age range to lead to diagnosis. The updates also ICD-O
!
by enable better reporting of antimicrobial resistance, with b. International Classification of External Causes of Injury -
tion codes that are more in line with the Global Antimicrobial ICECI
Ixes Resistance Surveillance System.
end International Classification of Functioning, Disability and
In this iteration of the ICD, special attention has been Health 1CF
-

dedicated to mental health. Simpler diagnostic descriptions

will make mental health diagnosis more accessible to d International Classification of Primary Care ICPC
health-care professionals globally. For instance, the ICD-11 e. Other terminologies such as OrphaNet and
nal list of post-traumatic stress disorder criteria have been SNOMED-CT
and reduced to facilitate easier diagnosis and improve access to
se treatment. Addictive conditions, such as gaming and The International Classification of Functioning,
ery hoarding disorders, have been added. Compulsive sexual Disability and Health (1CF) (140)
1, behaviour was included as an impulse control disorder. The ICF is a framework for organizing and documenting
xth The International Classification of Diseases 11th Revision information on functioning and disability (WHO 2001). It
ry. has been adopted by the World Health Assembly in 2019 conceptualizes functioning as a"dynamic interaction
in and it will come into effect from 1st January 2022. between a person's health condition, environmental factors
and personal factors".
The 1CD-11 contains following chapters
Ith ICF provides a standard language and conceptual basis
Certain infectious and parasitic diseases. for the definition and measurement of disability, and it
al 2.Neoplasms.
a provides classification and codes. It integrates the major
ch 3. Diseases of blood and blood forming organs. models of disability the medical model and the social
rS, 4 Disorders of the immune system. model- as a bio-psycho-social synthesis. It recognizes the
role of environmental factors in the creation of disability, as
Endocrine, nutritional and metabolic diseases. well as the health conditions.
OMental, behavioural or neurodevelopmental disorders Functioning and disability are understood as umbrella
19
7Sleep-wake disorders. terms denoting the positive and negative aspects of
8Diseaseof the visual system.
d
.
9Diseases of the nervous system.
Diseases of the ear and mastoid process.
11. Diseases of the circulatory system.
functioning from a biological, individual and social
perspective. 1CK theretore provides definitions and
categories in neutral language, wherever possible. ICF is
aetiology - neutral, i.e., disability is not differentiated by
aetiology. The ICF covers the entire life span. ICF organizes
12. Diseases of the respiratory system. information in two parts. Part 1 deals with functioning
13 Diseases of the digestive system. disability while part 2 covers contextual factors. and
Each part
14. Diseases of the skin. has two components:

the herd immunity
is sufficiently high, the occurrence
dmic iis regarded as highly unlikely. If
epidemic
of
an immunity is maintained, and stepped that high level
up, by
of nization programme, to the point an on-going
where the
Sceptible persons are reduced to a small proportion of the
ulation, it may leac (but not necessarily) to eliminatioon
Podisease
the in due course. This has been achieved in such
of theria and poliomyelitis. In the case of
diseases as
allpox, however, it may be mentioned that it was not herd
nity (although important as it was) that playeda
in its eradication, but elimination of the source
cTucial role
f infection, by surveillance and Containment measures.
with the abolition oi vaccination against smallpox, the herd
immunity in the case of smallpox will naturaily tend to
decline with the passage of time. In the case of tetanus,
however, herd immunity does not protect the individual.
Studies have shown that it is neither possible nor
necessary to achieve 100 per cent herd immunity in a
population to halt an epidemic or control disease, as for
example, eradication of smallpox and poliomyelitis. Just
how much less than 100 per cent is required above which
the disease may no longer exist, is a crucial question.
The proportion of immune individuals in a population,
above which a disease may no longer persist, is herd
immunity threshold. It's value varies with the virulence of the
disease, the efficacy of the vaccine and the contact
parameter for the population.
Herd immunity may be determined by serological surveys
(serological epidemiology).
IMMUNIZING AGENTS
The immunizing agents may be classified as vaccine5,
immunoglobulins and antisera.
Vaccines
Over the last century, vaccination has been the most
effective medical strategy to control infectious diseases.
Smallpox has been eradicated world-wide and poliomyelitis
has been almost eradicated. Most viral and bacterial
diseases traditionally affecting children world-wide are now
preventable by vaccines. Vaccination is estimated to save at
least 2-3 million lives every year. The vaccines currently
used are as shown in Table 29.
TABLE 29
Vaccines currently in use
IMMUNIZING AGENTS 111
substance designed to
vaccine is an immuno-biological a given disease. t
produce specific protection against antibody and other
Stimulates the production of protective
from live
mmune mechanisms. Vaccines may be prepared organisms,
moditied organisms, inactivated or
killed
of these.
extractedcellular fractions, toxoids or combination
a. Live vaccines
polio) are
Live vaccines (e.g., BCG, measles, oral organisms.
prepared from live or wild (generally attenuated)
hese organisms have been passed repeatedly
in the
lost
tissue culture or chick embryos and have
laboratory in
their
disease but retain
their capacity to induce full-blown potent
immunogenicity. In general, live vaccines are more
immunizing agents than killed vaccines, the reasons being:
(1) live organisms multiply in the host and the
resulting
antigenic dose is larger than what is injected, (ii)
live
minor antigenic
vaccines have all themajor and
components, (ii) live vaccines engage certain tissues of the
body, as for example, intestinal mucosa by the oral polio
vaccine, and (iv) there may be other mechanisms such as
the persistence of latent virus.
Live vaccines should not be administered to persons with
immune deficiency diseases or to persons whose immune
response may be suppressed because of leukaemia,
ymphoma or malignancy or because of theraPy with
corticosteroids, alkylating agents, antimetabolic agents, or
radiation (117, 118). Pregnancy is another contraindication
unless the risk of infection exceeds the risk of harm to the
foetus of some live vaccines.
When two live vaccines are required they should be given
either simultaneously at different sites or with an interval of
atleast 3 weeks. n the case of live vaccines, protection is
generally achieved with a single dose of vaccine. An
additional dose is given to ensure seroconversion, e.g., 95 to
98 per cent of recipient will respond to single dose of
measles vaccine. The second dose is given to ensure that
100 per cent of persons are immune. The other exception is
polio vaccine which needs three or more doses to be given
at spaced intervals to produce effective immunity. Live
vaccines usually produce a durable immunity, but not
always as long as that of the natural infection.
Live vaccines must be properly stored to retain
effectiveness. Serious failures of measles and polio

loxoid/Protein Polysaccharide Glycoconjugate Recombinant

Live attenuated Killed whole organism
Tuberculosis (BCG) Diphtheria Pneumococcus Hib HBV
Typhoid
Yellow fever Cholera Tetanus Meningococcus Pneumococcus Lyme disease
Polio OPV Acellular Pertussis Hib MenACWY Cholera toxin B
Plague
Anthrax Typhoid (Vi HPV
Measles Pertussis
Iníluenza subunit COVID-19
Mumps Influenza
Rubella Tuphus
yphoid Polio (IPV)
Varicella Rabies
Rotavirus JE
Cholera TBE
old adapted infuenza HAV
Rotavirus reassortants COVID-19
Zoster

calmete Guerin, HAV hepatitis A virus; HBV hepatitis rus;pol10 vaccine; TBE tick-borne encephalitic
5 HibHaemophilus influenzae type b: vated
BEG
Bacille
Polio vaccine, JE Japanese encephalitis; MenmeningocoCcus, oral
Source (116)
 EPIDEMIOLOGIC METHODS more stable thaan live
EPIDEMIOLOGY AND They are often
PRINCIPLESOF circulating antibody.
112 refrigeration attenuated vaccines. attenuated vaccines versus inatvated
from inadequate of some of
Some featuresare listed in Table 30 and
immunization have resulted
liery
prior to use (killed) vaccines field of vaccines are ted in
developments in the
b. Inactivated or
killed vaccines virus or important
are produced by growing Table 31. TABLE 30
Inactivated vaccines inactivating them with
media and then the ot killed and live vaccino
nes
bacteria in culture(usually formalin), when injected intosafe Comparison of characteristics
or chemicals They are usually Killed Live
heat active immunity. example,
body they stimulate efficacious than live vaccines. For Characteristic
vaccine vaccine
but generally, less protection. The
vaccine offers only 50 per cent per cent in Mutiple Single
cholera 80
pertussis vaccine is about years after Number of doses No
efticacy of 3 doses of almost "'nil 12 Yes
years, and Need for adjuvant
the first threeKilled vaccines usually require a primary series Shorter Longer
immunization.
produce an adequate
antibody Duration of immunity Lower Greater
of vaccine to required. Effectiveness of protection
of 2 or 3 doses "booster" injections are natural infection)
response, and in most cases following the use of inactivated (more closely mimics IgG lgA and lgG
The duration of immunity Inactivated polio Immunoglobulins produced
to many years. Poor Yes
vaccines varies from monthseffective vaccine, the widespread Mucosal immunity produced Yes
vaccine has been quite an has led to the elimination of Cell-mediated immunity produced
Poor
use of which in certain countries usually administered by Possible No
are Residual virulent virus in vaccine
the disease. Killed vaccines route. No Possible
subcutaneous or intramuscular Reversion to virulence
infective agent No Possible
Because the vaccine is inactivated,
the Excretion of vaccine virus and contacts
individual and therefore, can transmission to non-immune
cannot grow in the vaccinated immunodeficient person. No Possible
not cause the disease, even in an Interference by other viruses in host
administration High Low
The only absolute contraindication to
their Stability at room temperature
to a previous dose.
is a severe local or general reaction
not affected by Source: (119)
Unlike live antigens, inactivited antigens are
TABLE 31
Milestones in vaccination

1798 Smallpox vaccine 1993 Japanese encephalitis vaccine.

1885 Rabies vaccine 1995 Varicella vaccine licensed.
1897 Plague vaccine 1995 Hepatitis A vaccine licensed.
1917 Cholera vaccine 1996 Acellular pertussis vaccine (DTaP) licensed for use
1917 Typhoid vaccine (parenteral) in young infants.
1923 Diphtheria toxoid 2000 Pneumococcal conjugate vaccine (Prevnar)
1926 Pertussis vaccine recommended for all young children.
1927 Tuberculosis (BCG) 2003 First live attenuated influenza vaccine licensed (FluMist)
1927 Tetanus tOxoid for use in 5 to 49 year old persons.
1935 Yellow fever vaccine 2003 First Adult Immunization Schedule introduced.
1940s DTP
2004 Inactivated influenza vaccine recommended tor all
1945 The first influenza vaccines children 6 to 23 months of age.
1955 Inactivated polio vaccine (1PV). 2004 Pediarix, a vaccine that combines the DTaP IPV, and
1955 Tetanus and diphtheria toxoids adsorbed (adult use, Td)
1961 Hep B vaccines, into one shot, is approved.
Monovalent oral polio vaccine
1963 Trivalent oral polio vaccine (OPV).
2005 Boostrix and Adacel, Tdap vaccines, are approved
1963 for teens.
The first measles vaccine
1967 Mumps vaccine 2005 Menatra, a new menigococcal vaccine is approved tor
1969 Rubella vaccine people between the age of 11 to 55 years.
1970 Anthrax vaccine 2006 Rota Teq is a new rotavirus
vaccine from Merck.
1971 Measles, Mumps, Rubella (MMR) ProQuad is a new vaccine
1978 vaccine Iicensed. that combines
Fluzone, the current flu vaccine. the MMR and Varivax vaccines
1980 for measles, mumps,
Smallpox declared eradicated
from the world.
rubella, and chicken pox
1981 2006 into a single shot.
Meningococcal polysaccharide Gardasil, the first HPV
groups A, C, Y, W135 combinedvaccine, 2007 A booster dose vaccine is approved.
1982 Hepatitis B vaccine
(Menomune) of Varivax, the chickenpox vaccine,
is recommended
1983 Pneumococcal vaccine, 23 2007 for all children.
valent The recommended
1988 Worldwide Polio Eradication flu vaccine, was
age for Flumist, the nasal spray
Initiative lowered to two years.
supported by Rotary International, launched; 2008
1990 The Vaccine Adverse CDC and others. Rotarix, a two dose
Reporting System (VAERS), 2009 Influenza-A rotavirus vaccine is approved.
programme monitoring a national 2011 (HN,)vaccine approved.
1990 Haemophilus influenzae the safety of vaccines established. FDA approved
the first vaccine (Menactra)
type B (Hib) polysaccharide meningococcal disease to preven
conjugate vaccine licensed
1990 Typhoid vaccine (oral) for infants. FDA approved in infants and toddlers.
1991 Boostrix Tdap (Glaxo
Hepatitis B vaccine recommended prevent tetanus, diphtheria Smith Klin) to
1991 Acellular pertussis for all infants. HPV vaccine and pertussis in older p
older children aged
vaccine (DITaP) licensed 2012 for adolescent
l5 months to six for use in Approved quadrivalent boys.
years old. 2013 Inactivated and formulation of
Source: (120) 2020 COVID-19 intranasal influenza fluarix.quadrivalent
vaccine-qua
 MMUNIZATICON SCHEDULES 135
TABLE 43
National Iminunization Schedule (NIS) for
children and pregmant wo1-n (vaccine-wise). iniants.
212} india
When to glve Site
/Vaccine Dose Route
Women
Pregnant
For
(TT) Early in pregnancy Intra-muscular Upper Arm
Tetanus Toxoid 0.5 ml
Tetanus&adult
(Td)-1
Diphtheria
TT/Td-2 4 weeks after TT-1 Intra-muscular Upper Arm
0.5 ml
TTTd-Booster received 2 TT doses in a pregnancy
If Intra-muscular Upper Arm
0.5 ml
within the last 3 years*"

For Infants
At birth or as early as possible Intra-dermal Left Upper Arm
Bacillus
Calmette 0.1ml (0.05ml
till one year of age until 1 month age)
Guerin (BCG)
Intra-muscular Antero-lateral
Hepatitis B- At birth or as early as possible 0.5 ml
within 24 hours side of mid-thigh
Birth dose
At birth or as early as possible 2 drops Oral Oral
Oral Polio Vaccine
(OPV)-0 within the first 15 days
Oral Oral
OPV1,2&3 At 6 weeks, 10 weeks & 14 weeks 2 drops
(OPV can be given till 5 years of age)
Intra-muscular Antero-lateral
Pentavalent 1, 2 & 3 At 6 weeks, 10 weeks & 14 weeks 0.5 mi side of mid-thigh
(can be given till one year of age)
Intra-muscular Antero-lateral
Pneumococcal Two primary doses at 6 and 14 weeks 0.5 ml side of mid-thigh
Conjugate followed by booster dose at 9-12 months
Vaccine (PCV)
3 drops Oral Orat
Rotavirus (RVV) At 6 weeks, 10 weeks & 14 weeks
(can be given till one year of age)
Intra dermal, two Right Upper
Two fractional dose at 6 and 14 weeks 0.1 ml ID
Inactivated Polio fractional dose Arm
Vaccine (IPV) of age
Sub-cutaneous Right Upper
0.5 ml
Measles Rubella 9 completed months-12 months. Arm
(MR) 1st dose (Measles can be given till 5 years of age)
Sub-cutaneous Left Upper Arm
0.5 ml
Japanese 9 completed months-12 months.
Encephelitis
JE)-1** Oral
1 ml Oral
Vitamin A (1st dose) At 9 completed months with (1 lakh 1U)
Measles-Rubella

For Children Intra-muscular Antero-lateral

0.5 ml side of mid-thigh
Diphtheria, 16-24 months
Pertussis &
Tetanus (DPT
booster-1 Sub-cutaneous Right Upper Arm
0.5 mi
MR 2nd dose 16-24 months Oral Oral
2 drops
OPV Booster 16-24 months Sub-cutaneous Left Upper Arm
0.5 ml
1F 2 16-24 months Oral Oral
2 ml
every
tamin A 16-18 months. Then one doseycars
(2 lakh IU)
2nd to9th dose) months upto the age of 5
Upper Arm
6 0.5 ml. Intra-muscular
DPTBooster:2 Intra-muscular Upper Arm
5-6 yearS 0.5 ml
10years & 16 years
within 3 years
e doseif previously vaccinated endemic districts after the campaign.
years Old during bl-annual rounds,
in collaboration with ICDs.
districts)
in select
neto is introduced
9th doses of Vitamin A can be
administered to children 1-5
Himachal Pradesh, Madhya Pradestn, Flaryana State
initiative), Uttar Pradesh (19 &

p selected states/districts: Bihar,

aasthan 18 districis)
Source (143A)
 IMMUNIZATION SCHEDULES 137
success of EPI is now being
seen to have Services or as part of disease elimination or eradication
tant long-term eftects on the traditional epidemiological
imns of major intectious diseases, often raising the average measure.
patterr
of incidence, the adolescent age group of 10-19 years Adolescence presents certain challenges for immunization
acent an important additional target group for in relation to lifestyle and other social issues, delivery while also
nization. In the pre-immunization era, large proportion offering special opportunities, such as a vaccine in
The vaccines ot
adults had disease induced immunity to common the setting of educational institutions.
ctions, now majority of individuals have vaccine induced interest are MR and MMR as part of measles outbreak
immunity, which may or may not have the same
long-term prevention or elimination campaign, Td as booster dose for
ctability. Questions theretore arise as to
policy and strategy neonatal tetanus elimination, hepatitis B, influenza, varicella
implications for post-infancy immunization programmes. and HPV vaccines etc.

The WHO Scientific Advisory Group of Experts to EPI

Immunization of health care workers: The information
has indicated the need to expand
Table 45 is provided by WHO to assist countries to develop
immunization activities policies for the vaccination of health care workers, as per the
heyond infancy, either as part of routine
immunization national vaccination schedule in use in their countries.
TABLE 45
Immunization of health care workers
Antigen Vaccination of Health Care Workers recommended
BCG BCG vaccination is recommended for unvaccinated TST- or IGRA-negative persons
in low and high TB incidence areas (e.g. health-care
at risk of occupational exposurTe
workers, laboratory workers, medical students, prison workers,
other individuals with occupational exposure)
Hepatitis B mmunization is suggested for groups at risk of acquiring infection who have not been vaccinated previously (tor
example HCWs who may be exposed to blood and blood products at work).
Polio All HCWs should have completed a full course
of primary vaccination against polio.
iphtheria HCWs who may haveoccupational exposure to C. diphtheriae. All health-care workers should be upto date with
immunization as recommended in their national immunization schedules.
Measles All HCWs should be immune to measles and proof/documentation of immunity
or immunization should be required as
a condition of enrollment into training and employment.
Rubella f rubellavaccinehasbeenintroducedinto the national programme, all HCWs should be immune to rubella and proof
documentation of immunity or immunization should berequired as a condition of enrollment into training and
employment.
Meningococcal One booster dose 3-5 years after the primary dose may be given to persoi considered to be at cor ed risk of
exposure, including HCWs.
Influenza HCWs are an important group for influenza vaccination. Annual immunization with a single dose is recommended.
Varicella Countries should consider vaccination of potentially susceptible health-care workers (i.e. unvaccinated and with no
history of varicella) with 2 doses of varicella vaccine
Pertussis HWCs should be prioritized as a group to receive pertussis vaccine
Antigen No current recommendation for vaccination of Health Care Workers
Tetanus There is currently no recommendation regarding HCWs.
Haemophilus The main burden of diseaselies in infants under 5 years of age. Work in a health care setting is not indicated as a
| influenzae
type b factor for increased risk. There is currently no recommendation regarding HCWs.
Pneumococcal The main burden of disease liesininfants under 5 years of age. Immunocompetent adults are not at an increased risk for
serious pneumococcal disease.HCWs are not indicated as a group at increased risk of pneumococcal disease.
Rotavirus Children are the target group for rotavirus vaccination as they have the greatest burden of disease. Adults including
HCWs are not at increased risk of severe disease.
HPV HCWs are not at increased risk of HPV. The primary target group for vaccination is girls aged 9-14.
dapanese Health-care workers are generally not at special risk of contracting JE. Workers at high-risk in endemic areas, such as
Encephalitis those involved in vector control, should be vaccinated.
Yellow Fever
Individuals in endemic countries and travellers to these countries should receive a single dose of yellow fever vaccine.
Work in a health care setting is not indicated as a factor for increased risk. There is currently no recommendation
regarding HCWs.
ick-borne Health-care workers are generally not at special risk of contracting JE. Workers at high-risk in endemic areas, such as
Encepalitis
those involved in vector control, should be vaccinated.
yphoid Typhoid vaccines should be employed as part of comprehensive control strategies in areas where the disease is endemic.
Work in a health care setting is not indicated as a tactor tor increased risk. There is currently no recommendation
regarding HCWs.
Cholera Cholera vaccines may be employed as part of comprehensive control strategies in areas where the disease is endemic as
well as to preventand respond to cholera outbreaks. here is currently no recommendation regarding HCWs.
1

Hepatitis Hepatitis A is transmitted through contaminated food and water or direct contact with an infectious person. HCWs
A are
ndicated as a group at increased risk of hepatitis infection.
A
Rabies notimay
Mumps PrEP be considered for medical professionals who regularly provide care to persons with rabies.
Routine mumps vaccination is recommended in countries with a well-established, effective childhood vaccinati
programme and the capacity to maintain high level vaccination coverage with measles and rubella vaccination.
HCWs
Dengue (CyDTD
are not indicated as a group at increased risk.
Source:(144A) HCWs are not at increased risk of dengue
 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS
autoclaving for 20 minutes at 20 lbs pressure. Alternatively,
the patient may be asked to spit in a sputum cup half filled
with 5 per cent cresol. When the cup is full, it is allowed to
stand for an hour and the contents may be emptied and
disposed off.
3. Room
Osually thorough cleaning, airing and exposure to direct
sunlight, when possible, for several hours will be sufticient. If
necessary, floors and hard surfaces in the room should be
prohibited for 48 hours (152). For chemical disinfection,
floors and hard surfaces should be sprayed or mopped with
one of the following disinfectants: chlorine preparations
Such as chlorinated lime in concentrations that leave 25 ppm
or more of free chlorine; formaldehyde solution at a
concentration of 1 per cent or more; phenolic disinfectants
such as 27, per cent cresol. The solution should remain in
contact with the surface for at least 4 hours before final
washing (152). '
On rare occasions, when fumigation is required, the gas
most commonly used is formaldehyde. It may be generated
by boiling commercial formalin in 2 volumes of water (500
mi of formalin plus 1 litre of water per 30 cu. metres of
space) in a stainless steel vessel, over an electric hot plate or
by adding potassium permanganate to commercial formalin
in large jars (170-200 gram to 500 ml of formalin plus 1 litre
of water per 30 cu. metres) (152). There is vigorous boiling
and liberation of formaldehyde gas. The room is kept closed
for 6-12 hours to allow disinfection. Formaldehyde
disintection is most effective at a high temperature and a
relative humidity of 80-90 per cent.
Special Disinfection Procedures
(In COVID-19 context)
Sanitization tunnel
It is a tunnel or gateway for the sanitization and
decontamination of items and people when combined with
appropriately atomized biocides and/or virucide spray.
These sanitary and decontamination tunnels and gates
represent a safe protection and entry for everyone, in
particular for those who work in close contact with groups
and are therefore at higher risk. It can be installed at the
entrance of public offices, pharmacies, supermarkets,
airports, hospitals, ports, stations and tor companies who
need to sanitize the workforce, goods, vehicles and
materials.
The tunnel creates an obligatory passage and is equipped
with internal arc-snaped atomizing nozzles that saturate the
environment. The nebulization system is connected to
control system capable of automatically mixing and
sanitizing products at percentage indicated by the
manufacturer. The liquid is sprayed in the form of mist for
6-8 seconds on the person walking through the tunnel.
Access to the tunnel is regulated by a traffic light with
motion detection. By placing a barrier floor inside the
sanitary gate, it is possible to sanitize the surface in contact
with the ground.
The chemical used isa hydrogen peroxide ànd
isopropyl alcohol with distilled water; (b) sodiumn
hypochlorite 1or material sanitization; (c)sodium
hypochlorite forhumans under PPE protection; and
(d) concentrated chemical free and alcohol free ayurvedic
solution with enriched 100 per cent silver nano particles.
iti
Presently, WHO advises against the use tunnel for
human use, as it can cause SKin irritation and respirator
atory
tract allergy; and it does not give protection from the
infective agent in the respiratory tract.
Guidelines on disinfection of common public
places including offices (156)
It provides interim guidance about the environmental
cleaning/decontamiation of common public places including
offices in areas reporting COVID-19.
1. Indoor areas including office spaces
Otfice spaces, including conference rooms should be
cleaned every evening after office hours or early in the
morning before the rooms are occupied. If contact surface is
visibly dirty, it should be cleaned with soap and water prior
to disinfection. Prior to cleaning, the worker should wear
disposable rubber b0ots, gloves (heavy duty), and a triple
layer mask.
Start cleaning from cleaner areas and proceed towards
dirtier areas.
All indoor areas such as entrance lobbies, corridors and
staircases, escalators, elevators, security guard booths,
oftice rooms, meeting rooms, cafeteria should be
mopped with a disinfectent with 1% sodium hypochlorite
or phenolic disinfectants.
High contact surfaces such as elevator buttons,
handrails/handles and call buttons, escalator handrails,
public counters, intercom systems, equipment like
telephone, printers/scanners, and other office machines
should be cleaned twice daily by mopping with a linen
absorbable cloth soaked in 1% sodium hypochloride.
Frequentiy touched areas like table tops, chair handles,
pens, diary files, keyboards, mouse, mouse pad, tea'
coffee dispensing machines etc. should specially be
cleaned.
For metallic surfaces like door handles, security locks,
keys etc., 70% alcohol can be used to wipe down
surtaces where the use of bleach is not suitable.
Hand sanitizing stations should be installed in ottice
premises (specially at the entry) and near high contat
surfaces.
In a meeting/conference/office room, if someone
coughing, without following respiratory etiquetes o
mask, the areas around his/her seat should be vacateu
and cleaned with 1% sodium hypochlorite.
the
Carefully clean the equipment used in cleaning9
end of the cleaning process.
Remove PPE, discard in a yellow disposable bag and
wash hands with soap and water.
he
In
addition, all employees should consider cleanin
work area in front of them with a disintecting wipe
use and sit one seat further away from others, it p0s5i
2. Outdoor areas
Outdoor areas have less risk then indoor areas due toai
$top
urrents and exposure to sunlight. These include bus snd
railway platforms, park, roads, etc. Cleanihed
disinfection eforts should be targeted to frequently tou
contaminated surfaces as already detailed above.
 SPECIAL. DISINFECTION PROCEDURE 145
Public toilets
3. Guidelines for preparation of 1% sodium
hitary workers must use separate set of hypochlorite solution
tnment for toilets (mops, nylon scrubber) cleaning
and seperate | Product Available chlorine 1per cent solution
cot for sink
and commode). They should alwau
dienosable protective gloves while cleaning a toilet. 1 part bleach to
Sodium hypochlorite 3.5%
-liquid bleach 2.5 parts water
1 part bleach to
Areas Agents Procedure Sodium hypochlorite5%
Toilet cleaner -liquid 4 parts water
NaDCC (sodium 60% 17 grams to
Toilet pot/ Sodium hypochlorite Inside of toilet pot/commode: 1 litre water
1%/detergent Scrub with the recommended dichloro-isocyanurate)
commode |

powder
Soap powder/long agents and the long handle 11 tablets to
handle angular brush angular brush.
NaDCC (1.5 g/ tablet) 60%
1 litre water
Outside: clean with tablets
recommended agents; Chloramine -powder 25% 80 g to 1 litre water
use a scrubber. Bleaching powder 70% 7g to 1 litre water
Any other As per manufacturer's Instructions
Lid Nylon scrubber Wet and scrub with soap
commode and soap powder and the nylon 4. Personal Protective Equipment (PPE)
powder/detergent scrubber inside and outside.
1% Sodium Wipe with 1% Sodium Wear appropriate PPE which would include the following
Hypochlorite Hypochlorite. while carrying out cleaning and disinfection work.

Toilet floor Soap powder/ .Scrub floor with soap powder

Wear disposable rubber boots, gloves (heavy duty), and
detergent and and the scrubbing brush
a triple layer mask
scrubbing brush Wash with water Gloves should be removed and discarded/damaged, and
nylon broom 1% .Use sodium hypochlorite a new pair worn.
Sodium Hypochlorite 1% dilution. All disposable PPE should be removed and discarded
Soap powder/
after cleaning activities are completed.
Sink Scrub with the nylon
detergent and scrubber. Hands should be washed with soap and water
nylon scrubber 1% Wipe with 1% sodium immediately after each piece of PPE is removed,
Sodium Hypochlorite hypochlorite. following completion of cleaning.
Showers Warm water, Thoroughly scrub the floors/ Masks are effective if worn according to instructions and
area Detergent powder tiles with warm water and properly fitted. Masks should be discarded and changed if
Taps and Nylon Scrubber detergent. they become physically damaged or soaked.
fittings 1% Sodium Wipe over taps and fittings
Hypochlorite with a damp cloth and Hand washing technique
70% alcohol detergent. Fig. 26 shows steps of hand washing technique with soap
Care should be taken to clean and water (156).
the underside of taps and
fittings.
Wipe with 1% sodium
hypochlorite/ 70% alcohol
Soap Detergent and Should be cleaned daily with Wet hands Apply enough soap to Rub hands
dispenserS water detergent and water and with water Cover all hand surtaces paim to palm
Rub back ot each hand
with palm of other hand
dried.i with fingers interlocked

Alcohol can be used to wipe down surfaces where the use

0%of bleach
isnot Chloroxylenol
suitable, e.g. metal: (4.5-5.5%)|
Benzalkonium Chloride or any other disinfectants found to be
etective against coronavirus may be usedas per
manufacturer's instructions. Rub palm to palm with Rub with back of fingers Rub each thumb
clasped Rub tips of fingers in
tingers interlocked to opposing palms with n oppsite
Always use freshly prepared 1% sodium hypochlorite. fingers interlocked
hand using a
rotational movement
opposite palm in a
Circular motion

DOnot use disinfectants spray on potentially highly

contaminated areas (such as toilet bowl or surrounding
Surfaces) as it may create splashes which can further
spread the virus. Rub each wrist with Rinse hands Use elbow to Dry thoroughly with
opposite hand water a
turn off tap
lo prevent cross contamination, discard cleaningin Single-use towel
material made of cloth (mop and wiping cloth)
ppropriate bags after cleaning and disinfecting. Wear
ew.pair of glove and fasten the bag, e1
sinfect all,cleaning equipment after use and before Hand washing should
using i
other areas. take 15-30 seconds

isinfect buckets bu soaking in bleach solution or rinsein

FIG.
hot water Hand washingtechnique26
with soap and water
46 PRINCIPLES OF EPIDEMIOLOGY AND EPIDEMIOLOGIC METHODS
Guidelines for use of mask (156)
The correct procedure of wearing triple layer surgical
mask is as follows:
1. Perform hand hygiene
2. Unfold the pleats; make sure that they are facing down.
3. Place over nose, mouth and chin.
4. Fit flexible nose piece over nose bridge.
5. Secure with tie strings (upper string to be tied on top ot
head above the ears lower string at the back of the
neck.)
6. Ensure there are no gaps on either side of the mask,
adjust to fit.
7. Do not let the mask hanging from the neck.
8. Change the mask after six hours or as soon as they
become wet.
9. Disposable masks are never to be reused and should be
disposed off.
10. While removing the mask great care must be taken not
to touch the potentialy infected outer surface of the
mask.
11. To remove mask first untie the string below and then the
string above and handle the mask using the upper
strings.
12. Disposal of used masks: Used mask should be considered
as potentially infected medical waste. Discard the mask
in a closed bin immediately after use.
INVESTIGATION OF AN EPIDEMIC
The occurrence of an epidemic always signals some
significant shift in the existing balance between the agent,
host and environment. It calls for a prompt and thorough
investigation of the cases to uncover the factor(s)
responsible and to guide in advocating control measures to
prevent turther spread. Emergencies caused by epidemics
remain one of the most important challenges to national
health administrations. Epidemiology has an important role
to play in the investigation of epidemics. The objectives of
an epidemic investigation are (3, 22, 153).
a. to define the magnitude of the epidemic outbreak or
involvement in terms of time, place and person.
b. to determine the particular conditions and factors
responsible tor the ocCurrence of the epidemic.
to identity the cause, source(s) of infection, and
modes ot transmission to determine measures
necessary to control the epidemic; and
d. to make recommendations to prevent recurrence.
An epidemic investigation calls for inference as well as
description. Frequently, epidemicinvestigations are called
for after the peak of the epidemic has occurred; in such
cases, the investigation is mainly retrospective. No step by
step approach applicable in all situations can be described
like a "cook-book" (153). However, in investigating an
epidemic, it is desired to have an orderly procedure or
practical guidelines as outlined below which are applicable
for almost any epidemic study. Some of the steps can be
done concurrently.
1. Verification of diagnosis
Verification of diagnosis is the first step in an epidemic
investigation, as it may happen sometimes that the report
may be spurious, and arise from misinterpretation of sin
and symptoms by the lay public. It is therefore necessary to
have the verification of diagnoSis on the spot, as quickly as
possible. It is not necessary to examine all the cases to arrivo
at a diagnosis. A clinical examination of a sample of cases
may wel suffice. Laboratory investigations wherever
applicable, are most useful to confirm the diagnosis but the
epidemiological investigations should not be delayed unti
the laboratory results are available.
2. Confirmation of the existence of an epidemic
The next step is to confirm if epidemic exists. This is done
by comparing the disease frequencies during the same
period ot previous years. An epidemic is said to exist when
the number of cases (observed frequency) is in excess of the
expected trequency tor that population, based on past
experience. An arbitrary limit of two standard errors from
the endemic occurrence is used to define the epidemic
threshold for common diseases such as intluenza (3). Often
the existence of an epidemic is obvious needing no such
comparison, as in the case of common-sour epidemics of
cholera, food poisoning and hepatitis A. These epidemics
are easily recognized. In contrast the existence of modern
epidemics (e.g, cancer, cardiovascular diseases) is not easily
recognized unless comparison is made with previous
experience
3. Defining the population at-risk
(a) Obtaining a map of the area : Before beginning the
investigation, it is necessary to have a detailed and current
map of the area. If this is not available, it may be necessary
to prepare such
oncerning
a map. It should contain information
natural landmarks, roads and the location ot all
dwelling units along each road or in isolated areas. The area
may be divided into segments, using natural landmarkS as
oundaries. This may again be divided into smaller sections.
Within each section, the dwelling units (houses) may be
lesignated by numbers.
(b) Counting the population: The denominator may be
elated tO the entire population or sub-groups or
a population. It may also be related to total events (see
age 45 for more details). For example, if the denominator is
ne entre population complete census of the population
a
by age and sex should be carried out in the defined area by
ouse-to-house visits. For this purpose lay health workers
in sufficient numbers may be employed. Using this
technique it is possible to establish the size of the
population. The population census will help in computing
the much-needed attack rates in various groups and
subgroups of the population later on. Without an
ppropriate denominator of "population at risk" attack rates
cannot be calculated.
4. Rapid search for all cases and their
characteristics
(a) Medical survey : Concurrently, a medical survey
should be carried out in the defined area to identify all case
including those who have not sought medical care, and
those possibly exposed to risk. ldeally, the complete survey
(screening each member of the population for the presenC
of the disease in question) will pick up all affected
individuals with symptoms or signs of the disorder. Lay
 MEASILES

recommended
second dose is
5
units/kg body weight up to amaximum of 625 units, However, admínistration of a up-to-date on vaccination
repeatdose in.3 weeks, if a high-risk palient remains Tor exposed people to bríng
them
future exposure (9
wied. Because VZIG appears to bind the varicella vacine, and for best protection against
including the need for
wo should not be given concomitantly (4). Several unresolved issues remain,
childhood vaccination wil
VACCINE booster doses, whether universal adolescence or adulthood
shift the incidence of disease to whether
2. severe disease, and
attenuated varicella virus vaccine is safe and
live With the possibility of more of herpes zoster.
vaccinafion might prevent development
A
ntlu recommended for children between 12-18 months
who have not had chickenpox.
of age
Rocommendations on dosage and interval between doses References Microbiology. (2007). 24th
1Jawetz, Melnick and Adelberg's Medical
arv by manuiacturer.oneMonovalent vaccine can be
A Lange Publication.
Epidemiological Record, No. 25. June 20. 2014
or two dose schedule (0.5 ml Ed.,
administered following
2. WHO (2014), Weekly Ministry
oach by subcutaneous injection. A 2 dose schedule is
3. Govt. of India (2019), National
Health Profile of India 2019,
rocommended for all persons aged 213 years. When 2 doses of Health and Family Welfare, New Delhi.
interval between doses is Current Medical Diagnosis and
are administered, the minimum 4. Lawrence, M., Tierney, Jr. (2008). Publication.
from 4 weeks to 3 months for children (12 months to freatment, (2008), 47th Ed., A Lange
Viral Infections of Humans
12 vears of age inclusive), and 4
or 6 weeks for adolescents 5. Weller, Thomas H. (1977). in
Control, Evans Alfred, S. et al {eds). 2nd ed.
of age and older). Epidemiology and
and adults (13 years Plenum Medical, New York.
Combination vaccines (MMRV) can be administered to Epidemiology and Clinical
6. Christie, A.B. (1980). Infectious Diseases:
MMRV are
children from 9 months to 12 years. It 2 doses of Practice, 3rd ed., Churchil Livingstone.
Maxcy-Rosenau: Public
used, the minimum interval between doses should be 7. Stephen, R Preblud and A.R. Hinman (1980).
Medicine, Last. J.M. (ed), 11th ed. Appieton-
4 weeks. It is preferred that the 2nd dose be administered Health and Preventive
years of Century-Crofts.
6 weeks to 3 months after the first dose or at 4-6 WHO (1985) BulI WHO 63: 433.
age (2). 89. CDC Pink Book (2019), Epidemiology and Prevention
of Vaccine
The duration of immunity is not known but is probably
10 Preventable Diseases.
years. Although the vaccine is very eifective in preventing 10. WHO (1985) Techn. Rep. Ser.. No.725.
caused by
disease, breakthrough infections do occur but are much 11. Bres, P: (1986) Public Health Action in Emergencies
Epidemics. Geneva, WHO.
milder than in unvaccinated individuals (usually less than 50
lesions, with milder systemic symptoms). Although the
vaccine is very safe, adverse reactions can occur as late
as MEASLES
4-6 weeks after vaccination. Tenderness and erythema at the (RUBEOLA)
injection site are seen in 25%, fever in 10-15%, and a
localized maculopapular or vesicular rash in 5%; a smaller An acute highly infectious disease of childhood caused by
percentage develops a diffuse rash, usually with five or fewer a specific virus of the group myxoviruses.
It is clinicaliy
vesicular lesions. characterized by fever and catarrhal symptoms of the upper
tract (coryza, cough), followed by a typical rash.
Spread of virus from vaccinees to susceptible individuals respiratory
is possible, but the risk of such transmission even to Measles is associated with high morbidity and mortality in
immuno-compromised patients is small, and disease, when it developing countries. Measles occurs only in humans. There
is no animal reservoir of infection.
develops, is mild and treatable with acyclovir. Nonetheless,
the vaccine, being a live attenuated virus, should not be Problem statement
given immunocompromised individuals. The use of
to
varicella vaccine may be considered in clinically stable HIv.
Measles is endemic virtually in all parts of the world. It
iniected children or adults with CD4+ T-cell levels 2 15
per tends to occur in epidemics when the proportion of
susceptible children reaches about 40 per cent (1). When the
cent including those receiving highly active antiretroviral
disease is introduced into a virgin community more than 90
LnerapyHIV testing. is not a prerequisite for varicella to per cent of that community will be infected (2). While
Vaccination (2). It is contraindicated in persons allergic
reasons, it is recommended that measles is now rare in industrialized countries, it remains a
neomycin For theoretic common ilness in many developing countries. The primary
1O1lowing vaccination, salicylates should be avoided for 6
weeks (to prevent Reye's syndrome).
reason for continuing high childhood measles mortality and
morbidity is the failure to deliver at least one dose of
Varicella vaccination is contraindicated during
pregnancy measles vaccine to all infants (3).
on pregnancy should be delayed for 4 wèeks after
pregnancy is not indicated The challenges for measles elimination include (1) weak
eination. Termination of immunization systems; (2) high infectious nature of measles;
Vaccination was carried out inadvertently during
pregnancy (3) populations that are inaccessible due to conflict; (4) the
(9) increasing refusal ot immunization by some populations;
POST-EXPOSUREPROPHYLAXIS (5) the changing epidemiology of measles which has led to
increased transmission among adolescents and adults;
1or post
Vccine Varicella vaccine is recommended (6) the need to provide catch-up measles vaccination to >130
OSUre administration to un-vaccinated healthy people million children in India; (7) the gaps in human and financial
evidence of immunity, to
Zmonths and without other resources at the country, regional and global levels (4).
should be
nt or modify the disease. The vaccine exposure In 1980, before widespread use of measles vaccine, an
adminis within 5 days after
to Chila thereas soon asnopossible
contraindication to use. Among estimated 2.6 million measles deaths occurred worldwide.
is Recognizing this burden, WHO and UNICEF developed an
protective efficacy. was reported as 290 per cent accelerated measles mortality reduction strategy of
exposure.
accination occurred within 3: days of
162 EPHEMIO1OGY OF COMMUNICABLE MSEASES

delivering 2 doses of mensles containing vaccine (MCV) to early stages of the rash. (d} COMMUNIC A
all childen through routine services and supplementary highly infectious during the prodromal n
Y
immunizing activities (SIAs). and improving disease of eruption. Communicability
Surveillancec. Inplementation of this strategy began in 2001 appearance ot the rash. The deciia n
Al the 2010 World Healtlh Assembly, member states period
approximately 4 days before and 4
chdorsed the tollowing targels to be met by 2015 as of the rash. Isolation of the patient daus af
more than covers the periodof he fro
mitestones towards eventual global measles eradication: fora
ol(e)rasn
(1) raise routine coverage with the first dose of MCV (MCV,)
to 290 per cent nationally, and 280 per cent in every district
SECOND ATTACK RATE Ther
type of measles virus. Intection
:ts onty
ne
confers
or cquivalent administrative unit; (2) reduce and maintain Most so-called second attacks ife
orr i
represent ertors
annual measles incidence to <5 cases per million; and either in initial or second illness (10)
(3) reduce measles morlality by 295 per cent in comparison
with the cstimated level in the year 2000 (5). Host factors
The Global Measles and Rubella Strategic Plan 2012-20 (a) AGE Affects virtually everyone
period saw a significant reduction in the measles and rubella childhood between 6 months and 3 in ia
-

disease burden. a steep increase in the introduction of a developing countries where environme
Second dose of measles-containing (MCV,) and rubella generally poor, and older children ustaltnd
developed countries (11). Following the
vaccines, and improvements in surveillance. During 2018,
approximately 346 million people received measles vaccine, the disease is noW seen in e
somewhat rl
vaccination through 45 supplementary immunization groups (12). This highlights the importance
ot
activities (SlAs) in 37 countries. Estimated measles-related serological checking of the immunity Status
deaths declined by 73 per cent and estimated cases by 76 per susceptible population. (b) SEX Incidence
cent from 2000 to 2018. It still accounted for an estimated (c) IMMUNITY : No age is immune it there was no
9.7 million cases and more than 140,000 measles related immunity. One attack ot measles generally confers
deaths worldwide during 2018 (6). Measles is responsible for immunity. Second attacks are rare. intants are prote
about 2 per cent of under-five mortality worldwide (8). maternal antibodies up to b months of age: in
maternal immunity may persist beyond months. In
In India. measles is
a significant cause of childhood
morbidity. Prior to the immunization programme, cyclical after vaccination Is quite solid and lcng-a
increase in the incidence of measles were recorded every (d) NUTRITION : Measles tends to be very severe
third year. With the increase in immunization coverage malnourished child, carrying a mortality upto 40 a

levels, the intervals between cyclical peaks has increased and
the intensity of the peak minimized. However, several
outbreaks are reported in tribal and remote areas. The
retrospective data indicate a declining trend of measles in
the country. During 1987 about 2.47 lakh cases were
reported, whereas, atter implementation of OIP, the number
of cases has come down to 20,895 with 34 deaths during the
year 2018.
The states majorly affected were West Bengal (4,886
cases and 8 deaths), Assam (2,361 cases), Jammu and
Kashmir (2,039 cases), Maharashtra (1,963 cases and 2
deaths), Delhi (1,371 cases and 12 deaths), Uttar Pradesh
(1,349 cases), and Rajasthan (1,067 cases and 3 deaths) (7).
The country is making significant progress towards the goal
of measles elimination and rubella/congenital rubella
syndrome control. The strategies for measles and rubella
elimination include: (1) 95 per cent coverage with measles
and rubella vaccination; (2) Case-based measles-rubella
surveillance with adequate laboratory support; (3) Linkage
with other child health interventions; and (4) Increased
public confidence and demand for immunization (8).
Epidemiological determinants
Agent factors
(a) AGENT: Measles is caused by an RNA paramyxovirus.
So far as is known. 1here is only one serotype. The virus
cannot survive outside the human body for any length of
time, but retains infectivity when stored at sub-zero
temperature. The virus has been grown in cell cultures.
(b) SOURCE OF INFECTION: The oly source of infection is
higher than in well-nourished children having meas
This may possibly be related to poor ceil-mediated i
Tesponse, secondary to malnutrition (141. Atdi
severely malnourished children have been shown to
measles virus for longer periods than berter 0
children indicating prolonged risk to themseives.
intensity of spread to others (15). Even in heatny a
attack of severe measles may be followed by We
precipitating the child into malnutrition.
Environmental factors
seaso
Given a chance, the virus can spread in ang
Curng
In tropical zones, most cases ot measles OCcur
nter
season. In temperate climates. measles is à
probably because people crowd together indoct.
Or measles are common in ndia during win mN
spring fJanuary to April). Population
ao alect epidemicity (16). In general, the less t
denstu
prevailing socio-economic conditions, tne tow
age at which children are attacked.
Transmission erson ®
Transmission occurs directly trom nuclei, ro
mainly by droplet infection and dropletn ne prs
Delore onset of rash until 4 days thereartei
entry is the respiratory tract. Intection tntilled
also considered likely as the virus.nts of
COnjunctiva can cause infection. Recp
vaccine are not contagious to otheTs tt
Incubation period trom
enp

a case of measles. Carriers are not known to Occur. There is Incubation period is commonly
aysnce of
Oypass
some evidence to suggest that subclinical measles occurs onset of fever, and 14 days to apped
more often than previously thought. (c) INFECTIVE measles infection is artificially easles
MATERIAL: Secretions of the nose, throat and respiratory espiratory tract (as with injection of livaerag
tract of a case of measles during the prodromal period and the ncubation period is somewhat shortene
164 EPIDEMIOLOGY OF COMMUNICABLE DISEASES
Prevention of measles
The following guidelines are important in combating
measles:
a. achieving an immunization rate of over 95 per cent,
and
b.on-going immunization against measles through
Successive generations of children.
1. Measles vaccination
Measles is best prevented by active immunization.
VACCINE Only live attenuated vaccines are
recommended for use; they are both safe and effective, and
may be used interchangeably within immunization
programmes. Person to person transmission of measles
vaccine strains has never been documented. The vaccine is
presented as a freeze-dried product. Before use, the
lyophilized vaccine is reconstituted with sterile diluent. Each
dose of 0.5 ml contains 21000 viral infective units of the
vaccine strain; this is also true when it is presented as an
MCV combination. Measles vaccine may also contain
sorbitol and hydrolysed gelatin as stabilizers, as well as a
small amount of neomycin, but it does not contain
thiomersal. In general, it is recommended that freeze-dried
vaccine be stored in a refrigerated condition (20). The
diluent must not be frozen but should be cooled before
reconstitution. Reconstituted measles vaccine loses about
50 per cent of its potency after 1 hour at 20°C; it loses
almost all potency after 1 hour at 37°C. The vaccine is also
sensitive to sunlight, hence it is kept in coloured glass vials.
After reconstitution, the vaccine must be stored in the dark
at 2-8°C and used within 4 hours.
Measles vaccine is available in monovalent (measles only)
form and in combination : measles-rubella (MR), measles-
mumps-rubella (MMR) vaccine, and measles-mumps-
rubella-varicella (MMRV) vaccine.
Reaching all children with 2 doses of measles containing
vaccine (MCV) should be the standard for all national
immunization programmes. In countries with ongoing
transmission in which the risk of measles mortality remains
high, MCV, should be given at age 9 months. MCV, should
be given between 15-18 months, as providing MCV, in the
2nd year of life reduces the rate of accumulation of
susceptible children and the risk of an outbreak. The
minimum interval between MCV, and MCV, is 4 weeks.
Every opportunity (e.g. when children come into contact
with health services) should be taken to vaccinate all
children that missed one or both MCV routine doses,
particularly those under 15 years of age. Policies which
prohibit use of vaccine in children >1 year of age, older
children and teenagers should be changed to allow these
individuals to be vaccinated.
In countries with low levels of measles transmission
(i.e. those that are near elimination or verified as having
eliminated endemic measles virus transmission), and
therefore the risk of measles virus infection among infants is
low, MCV, may be administered at 12 months of age to take
advantage of the higher sero-conversion rates achieved at
this age. In these countries, the optimal age for delivering
MCV, is based on programmatic considerations to achieve
the highest coverage of MCV, and, hence, the highest
population immunity. Administration of MCv, at 15-18
months. of age ensures early protection of the individual,
slows accumulation of susceptible young children, and may
correspond to the schedule for other routine immunizations
(for example, a DTP-containing booster, PCV
meningococcal vaccines). This measure also supporte
establishment of a policy on immunization and other heals
coverar
interventions in the second year of life. If MCV, ge
high (>90%) and school enrolment is high (>95%
administration of routine MCV, at school entry may prov
an effective strategy for achieving high coverage and
preventing outbreaks in schools (22).
MCV administered before 9 months of age should be
considered a supplementary dose and recorded on the
child's vaccination record a MCV" hildren who receive
MCV, should also receive MCV, and MCV, at the
recommended ages according to the national schedule. A
supplementary dose of MCV should be given to infants from
:
a
6 months of age (1) during measles outbreak as part of
intensified service delivery; (2) during campaigns in settings
where the risk of measles among infants < 9 months of age
remains high (e.g. in endemic countries experiencing regular
outbreaks); (3) for internally displaced populations and
refugees, and populations in contlict zones; (4) for individual
infants at high risk of contracting measles (e.g. contacts of
known measles cases or in settings with increased risk of
exposure during outbreaks such as day-care facilities;
(5) for infants travelling to countries experiencing measles
outbreaks; (6) for infants known to be HIV-infected or
exposed (i.e. born to an HIV-infected woman) (22).
Given the severe course of measles in patients with AIDS,
measles vaccination should be routinely administered to
potentially susceptible, asymptomatic HIV infected children
and adults. Vaccination may even be considered for those
with symptomatic HIV infection if they are not severely
immuno-suppressed according to conventional definitions.
In areas where there is a high incidence of both HIV
infection and measles, an initial dose of MCV may be
offered as early as age 6 months (recorded as MCV). The 2
routine doses of MCV (MCV, and MCV,) should then be
administered to these children according to the national
immunization schedule (22).
CONTRAINDICATIONS TO VACCINATION (23) MMR
and other measles-containing vaccines are not
recommended for HIV-infected persons with evidence of
severe immunosuppression. MMRV is not approved for and
should not be administered to a person known to be infected
with HIV.
Persons with moderate or severe acute illness should not
be vaccinated until the patient has improved. This
precaution is intended to prevent complicating the
management of an ill patient with a potential vaccine
adverse reaction, such as fever. Minor illness (e.g., otitis
media, mild upper respiratory infections), concurrent
antibiotic therapy, and exposure to or recovery from other
illness are not contraindications to measles vaccination.
Receipt of antibody-containing blood products
(e.g., immune globulin, whole blood or packed red blood
cells, intravenous immune globulin) may interfere witn
sero-conversion after measles vaccine. The length of time
that such passively acquired antibody persists depends on
the concentration and quantity of blood product received,
For instance, it is recommended that vaccination be delayea
tor3months following receipt of immune globulin 1o
prophylaxis of hepatitis A; a 7 to 11 months delay 5
recommended following administration of intravenous
immune globulin, depending on the dose.
iReplication of vaccine viruses can be prolonged
persons who are immunosuppressed or immunodeficien
 MEASI.ES 165
passively immunized
overe immunosuppression can be due to a variety of 3-4 days of exposure. The person 8-12 weeks later. The
onditions. incliding congenital immunodeficiency, HIV should be given live measles vaccine secause of
oction. leukaemia, Iymphoma, generalized malignancy, or need for immunoglobulin is now much reduced
the availability of an effective live attenuated vaccine.
orapU with alkylating agents, antimetabolites, radiation,
or
rge doses ol corticostleroids. For this reason, persons who framework
re severely immunocom Oised 1or any reason should not GIobal mensles and rubella strategic
e given measles containing vaccine. 2021-2030 (MRSF) (6)
Women known to be pregnant should not receive measles The measles and rubella strategic framework
2021-2030
that will guíde the
vaccine. Pregnancy should be avoided for 4 weeks following aims to provide a high-level framework
MMR vaccine. Close contact with a pregnant woman is not a regional and national strategies and operationai plans.
of the Immunization Agenda 239
ontraindication to MMK vaccination of the contact. within the umbrella
Breastfeeding is not a contraindication to vaccination of structure. It aims to establish convergence with other key
either the woman or a breastfeeding child. agency strategy documents. envisions
It "A world free from
is
Do tuberculin skin testing (TST) at the same visit as MMR measles and rubella". The goal for the 2021-2030 period
regional measles and rubella
vaccination. or delay 1TST at least 4 weeks if MMR is given to achieve and sustain the
first. The least favoured option is to do TST first and
elimination goals".
administer MMR When s is read as it delays the The core strategies identified in the 2012-20 MRSP wil
vaccination. TST has no effect on the response to MMR remain relevant in the post 2020 period. The strategic
vaccination. However, measles containing vaccines may priorities are as follows
transiently suppress the response to TST in a person infected 1. Incorporate all measles and rubella activities, including
with M. tuberculosis (23). surveillance and case management, as key components
ADMINISTRATION: The reconstituted vaccineis of eftective PHC system in support of universal heaith
generally injected Subcutaneously, but it is also effective coverage.
when administered intramuscularly. 2. Improve ownership and accountability ot measles and
REACTIONS When injected into the body, the rubella goals and targets at all leveis and improve
attenuated virus multiplies and induces a mild "measles community demand for uptake of measles and rubella
illness (fever and rash) 5 to 10 days after immunization, but containing vaccines.
in reduced frequency and severity. This may occur in 15 to 3. ldentify and close immunity gaps to measles and rubella
20 per cent of vaccinees. The tever may last for 1-2 days by ettectively utilizing alll relevant contacts berwean
and the rash for 1-3 days. There is no cause for alarm.he individuals and the health system. establishing o
vaccines now given rarely cause severe reaction (10). There strengthening new contact points where required. annd
1S no spread of the Virus irom the vaccinees to contacts. using targeted approaches to reach under-served
IMMUNITY: The vaccine has convincingly demonstrated populations.
to provide immunity to even severely malnourished 4. Leverage the life-course approach for delivery of ne
children. Immunity develops 11 to 12 days after vaccination second routine dose of measles and rubella containinng
and appears to be of long duration, probably for life. One vaccines and for catch-up vaccination: and ntegrate
age appears to measles and rubella activities with other health and non
dose of tne vaccine given atll-12 months of 98 per cent
give 95 per cent protection and with two doses health activities.
protection. Infants vaccinated at the age of 9 months show 5. Ensure outbreak preparedness for timely detection and
sero-conversion of about 90 per cent (20). ffective response to limit the spread of measles andd
CONTACTS Susceptible contacts over the age of rubella and reduce related morbidity and martaliry.
may be protected against measles with
months
measles vaccine, provided that this is given within 3 days of
6. Ensure continued, timely and quality supply of measies
and rubella containing vaccines, vaccination supPpies
exposure. This is because, the incubation period of measles
and laboratory reagents and that measies and rubellaa
Induced by the vaccine is about 7 days, compared with ctivities, including surveillance. are sustainably
10 days for the naturally acquired measles.
financed.
ADVERSE EFFECTS OF VACCINE Toxic shock
7. Foster research and innovation to overcome barriers to
Syndrome (TSS) occurs when measles vaccine 1s achieve high measles and rubella population immunity
Contaminated or the same vial is used for more than one and to generate and use high quality disease and
not
Eession on the same day or next day. The vaccine should programme data.
De used after 4 hours of opening the vial. TSS is totally
preventable and reflects poor quality of immunizanon Outbreak control measures
watery
VICes. The symptoms of TSS are typical. Severe within iew The following control measures nave been
Larnoea, vomiting and high fever are reported
: (a) Isolation tor days atter onset of rash,
nours of measles vaccination. There are usually a cluster ol recommended
as all infants vaccinated from contaminated vial will be (b) immunization of contacts within 2 days ot exposure
es This may cause death within 48 hours. Case
(if vaccine is contraindicated, immunogtabulin should be
ected. given within 3-4 days ot exposure), and (c) prompt
tatality rates are high (20).
immunization at the beginning of an epidemic is essential ta
2. Immunoglobulin limit the spread.
ot
easles may be prevented by administration Eradication of measles
ThOgobulin (human) early in the incubation period.
It is believed that measles, like
aOse recommended by WHO is 0.25 ml per kg of body snmallpox, is amenable to
Egnt see Table 33 on page 116). It should be given witnin eradication. Measles immunization has in its favour the fact

10 to 14 days after the rash.
(C) RASH: The
rash is often
for
indication of the disease in children. It appears
ars irst
of #h first
the tace, usuaiy within 24 hours
omal symptoms. Tt is a minute, discrete, pinkish,
PaCular rash and not connuent as the rash of measles
and it
he topruritic. Conjunctivitis may occur. The rash spreads
molu the trunk and extremifies, by which time it is often
no longer apparent On
no neace.
nd clears more rapidly than Ihe
rash spreads much
the rash of measles. It
anears altogether by the third day. The rash is
an
nconstant feature oI the disease; it IS absent in
n The incidence of rubella infection subclinical
without rash may
he upto 25 per cent (4). (d) COMPLICATIONS:
In rare
instances artnraigla may occur in several joints in
adults,
especially young Women..Encephalitis is very rare.
Thrombocytopenic purpura nas also been observed as a
complication. Mention has been made already about the
congenital maltormations.
Diagnosis
Because of its mildness and variability of symptoms, the
disease can go unrecognized unless it is an epidemic. A
definitive diagnosis of rubella is possible only through virus
isolation and serology. Throat swabs should be cultured for
virus isolation; it takes longer than serological diagnosis. The
haemagglutination inhibition(HI) test is a standard
serological test for rubella. However, erum must be
pretreated to remove non-specific inhibitors before testing.
ELISA tests are preterred because serum pretreatment is not
required and they can be adapted to detect specific IgM.
Detection of lgG is evidence of immunity because there is
only one serotype of rubella virus. To accurately confirm a
recent rubella infection, either a rise in antibody titer must
be demonstrated between two serum samples taken at least
10 days apart or rubella-specific lgM must be detected in a
single specimen. It is critically important in a pregnant
woman (6).
cONGENITAL RUBELLA SYNDROME (CRS)
Con nital rubella syndrome (CRS) refers to infants bon
with defects secondary to intrauterine infection or who
manifest symptoms or signs of intrauterine intection
sometime after birth (5). Congenital infection is considered
to have Occurred if the intfant has lgM rubella antibodies
not cross
Shortly after birth (as lgM antibodies do
placenta, their presence indicate that they must have been
synthesized by the infant in utero) or if lgG antibodies persist
Or more than 6 months, by which time maternally derived
antibodies would have disappeared. ntrauterine intection
wIth. rubella is associated with chronic persistence of the
VIrus, in the newborn. At birth, virus is easily detectable in
pharyngeal secretions, multiple organs, cerebrospinal Iuia,
rne, and rectal swabs. Viral excretion may last for 12-18
months after birth, but the level of shedding gradualy
decreases with age (6)
Rubella infection inhibits cell division, and this
probably the reason for congenital malformations and low
Weight (7). The classic triad of congenital detects
ainess, cardiac malformations and cataracts. infected (i.e. experienced a severe allergic reaction after a previous
ubella infection in a woman who becomes
or symptomatic disease) just causes before
c mptomatic upto the first 8-10 weeks of gestation
amal
n and
e congenital abnormalities in upto 90% of intections,
may result in miscarriage or stillbirth. Congenitalare rare
ales associated with maternal rubella infection
RUBELLA
after the 16th week of pregnancy, although sensorineura
nearing deficits may occur after exposure upto week Z0 OI
gestation. The defects associated with CRS include
ophthalmic (e.g. cataracts, microphthalmia, glaucoma,
piqmentary retinopathy, chorioretinitis), audo
sensorineural deafness), cardiac (e.g. peripheral pulmonar
artery stenosis, patent ductus arteriosus or ventricular septal
detects) and craniofacial (e.g. microcephaly) anomalies. CRS
can also present with other manifestations, Such as
meningoencephalitis, hepatosplenomegaly, hepatitis,
tnrombocytopenia, interstitial pneumonitis and radio-
lucency in the long bones (a characteristic radiologica
pattern of CRS). Infants who survive the neonatal period
may nave serious developmental disabilities (such as autism,
Visual and hearing impairment), and developmental delay.
Viral shedding can continue in CRS cases beyond I year or
age, which may result in virus transmission (2).
Prevention
The currently used rubella vaccines are based on the live
attenuated RA 27/3 strain. Most rubella vaccines are
available in combination with other vaccine antigens such as
measles, mumps and varicella (MR, MMR, MMRV,
respectively) and also in a monovalent formulation. Each
dose of an RCV contains a minimum number of infectious
units (2l000 plaque-forming units or 50% cell culture
infectious dose). When stored at 4°C, most RCVs have a
shelf-life of 2-3 years. Monovalent rubella, MR and MMR
vaccines should be stored at 2-8°C, protected from light.
Diluent vials may be stored at ambient temperatures but
must never be frozen. The standard volume of a single dose
of RCV is 0.5 ml, and the vaccine is sually injected
subcutaneously. The preferred site of injection is the
anterolateral thigh or outer aspect of upper arm, depending
on the age of the individual (2).
Because rubella is not as highly infectious as measles and
because the effectiveness of 1 dose of an RCV is >95%,
even at 9 months of age, only 1 dose of rubella vaccine is
required to achieve rubella elimination if high coverage is
achieved. However, when combined with measles
vaccination, it may be easier to implement a second dose of
RCV's using the same combined MR vaccine or MMR
vaccine for both doses. RCV's can be administered
concurrently with inactivated vaccines. As a general rule,
the live vaccines should be given either simultaneously with
RCV's, or at least 4 weeks apart. An exception to this is oral
polio vaccine, which can be given at any time betore or after
RCV's without interfering in the response to either vaccine.
Interference may occur between MMR and yellow fever
vaccines if they are simultaneously administered to children
<2 years of age (8).
The vaccine induced immunity persists for life time. In
order to provide direct protection against rubella, all non-
pregnant women of reproductive age who are not already
vaccinated or who are sero-negative for rubella receive one
is dose of RCV (2).
Precautions and contraindications
are
RCVs should not be given to anyone who has
vaccine dose or vaccine component. It is recommended not
provide the vaccine to those with active TB or severe
immunodeficiency (including individuals with symptomatic
HIV infection, AlDS, Congenital immune disorders,
malignancies or aggressive immunosuppressive therapy).
 168 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Rubella vaccination should be avoided in pregnancy age of incidence of mumps is higher than with mone
oy
because of a theoretical (but never demonstrated) risk of chickenpox or whooping cough. However, no age is
teratogenic outcomes. Women planning a pregnancy are if there is no previous immunity. he disease tends
more severe in adults than in children. (b) IMMUNITY.
t
advised to avoid pregnancy for 1 month after rubella
vaccination. Inadvertent vaccination with RCV during attack, clinical or subclinical, is assumed to induce lifele
pregnancy is not an indication for terminating the immunity. There is only one antigenic type of mumps vir
pregnancy. People who receive blood products wait at least and it does not exhibit signiticant antigenic variation (
3 months before vaccination with RCV, Most infants below the age of 6 months are immune becau
and, if possible,
avoid administration of blood products for 2 weeks of maternal antibodies.
after
vaccination (2).
Global measles and rubella strategic Environmental factors
(2021-2030) framework Mumps is largely an endemic disease. Cases occ
Refer to page 165 for the details.
throughout the year, but the peak incidence is in winter an
spring. Epidemics are often associated with overcrowding,
References Mode of transmission
1. WHO (2016), Rubella Fact
sheet, March 2016. The disease is spread mainly by droplet infection
WHO (2020), Weekly Epidemiological ane
Record, No. 27, 3rd July 2020. after direct contact with an infected person
3. Fovbes, J.A. (1969).
American J. Dis.Child., 118
4. Valman, H.B. (1981), :5
Brit.Med.J. 283: 1038. Incubation periood
Walter, A.0. et al (1984). JAMA
251 1988.
6. Jewetz, Melnick Varies from 2 to 4 weeks, usually 14-18
and Adelberg's Medical Microbiology, 28th days.
7. Dudgeon, J.A. ed., 2019.
(1969). Am.J.Dis.Child, 118:35.
WHO (2020), Summary
of WHO
Routine Immunization for Children. Position Papers Recommended
Clinical features
Mumps is a generalized virus infection. In
of cases mumps infection is clinically 30-40 per cent
MUMPS clinically apparent cases, it is non-apparent. In
swelling in either one or both the
characterized by pain and
An acute infectious involve the sublingual and parotid glands but may also
disease caused by an RNA submandibular glands. Often the
classified as genus virus child complains of "ear ache"
Rubulavirus of the family on
paramyxoviridae which has a predilection
for glandular and the onset of swelling. There may the affected side prior to
nervous tissues. Clinically, be pain and stiffness on
the opening the mouth before the
suppurative enlargement and disease is recognized by non- swelling of the gland
parotid glands. Other organs tenderness of one or both the evident. Mumps may also affect
the testes, pancreas, CNS,
is
may also be involved. ovaries, prostate, etc. In severe
Constitutional symptoms vary,
disease occurs throughout or may be inapparent. The headache and other constitutionalcases, there may be fever
the world. Although morbidity from 3-5 days. The swelling symptoms which may
rate tends to be high, mortality subsides slowly over 1-2 weeks
last
rate is negligible. COMPLICATIONS
In most parts of
mumps in the absence of
the world, the annual incidence These include orchitis,Though frequent, are not serious
of
immunization is in the range
100-1000 cases/100,000 population of encephalitis, thyroiditis, ovaritis, pancreatitis, meningo
with epidemic peak neuritis, hepatitis and myocarditis
lesticular swelling and tenderness
every 2-5 years. Natural
infection with this virus is
to confer lifelong protection thought the most common denote orchitis, which
(1). mumps in adults. It extrasalivary gland manitestation
cases. High fever is unilateral in about 75 per
Agent factors
develops typically usually accompanies orchitis, whie
cent
(a) AGENT The
causative about 25-40 per cent 7-10 days after the onset of
a RNA virus of the myxovirus agent, Myxovirus parotiditis is of post-pubertal men (4).parotitis
family. The virus can orchitis is rare and Bilater
readily in chick embryo or be grown lead to sterility is the assumption that mumps orchitis
serotype. (b) SOURCE OF tissue culture. There is only one nausea and vomiting ill-founded (5). Upper abdominal
subclinical cases. SubclinicalINFECTION: Both clinical and suggest pancreatitis. Mumps
pal
per cent of all cases (2) cases which account for 30-40 leading cause of
appear to be responsible 4 per cent pancreatitis in children. It occurs
maintaining the cycle of infection. for of patients (6). Lower in ab
The virus can be isolated Ovarian enlargement suggest abdominal pain
from the saliva or from
Stenson's duct. Virus hasswabs taken from the surface of
5 per cent
of post pubertal oophoritis which occur
also been found in the While some instances women, usually
urine, human milk and on blood, following mumps of diabetes have unilatera
OF COMMUNICABILITY occasion in the CSE (c) PERIOD infection, occurred in cn
a causal relationship
be demonstrated
onset of symptoms and a Usually 4-6 days before the
:

week or more thereafter. (5). Rarer complications

deafness, polyarthritis, has
period of maximum infectivity is The include
of parotitis. Once the swelling just before and at the onset
cerebellar ataxia, hydrocephalus, encep
Encephalitis facial palsy
the case may be regarded of the glands has subsided, is associated and transverse
as no longer infectious. neurologic with cerebral
and sometimes oedema
(d) SECON ATTACK
RATE : Estimated manifestations
to be about 15% of mumps
86 per cent.
much smaller patients may develop death
encephalitis. Mumps proportion (0.02-0.03%) meningits
Host factors
sensorineural deafness, is one of the main
may
(a) AGE AND SEX Mumps: 100,000 mumps which affects infectious
parotitis in children in the age is the most frequent cause of cases (6) approxima
group 5-9 years. The Mumps infection
average associated with in the first
a 25% incidence trimester of pr
of spontaneous

Reve syndrome (fatty liver with encephalopathy)
nd Severe complication of influenza, usually A and isBatype,rare
particularly in young children between 2
age, It consists of and 16 years of
rapidly progressive hepatic failure and
ncephalopathy, and there is about 10-40 per
cent mortality
rate, The pathogenesis is
unknown, but the syndrome is
associated with aspirin use in a variety of viral
infections (7).
AVIAN INFLUENZA (8)
(BIRD FLU)
Avian influenza reiers to a large group of different
influenza viruses that primarily affect birds. On rare
occasions, these bird viruses can infect other species,
including pigs and humans. The vast majority of avian
influenza viruses do not intect humans. However, avian
HN, is a strain with pandemic potential, since it might
ultimately adapt into a strain that is contagious among
humans. Once this adaptation occurs, it will no longer be a
bird virus -
it will be a human influenza virus. Influenza
pandemics are caused by new influenza viruses that have
adapted to humans. Health experts have been monitoring a
new and extremely severe influenza virus the HN, strain
for almost 15 years. Fortunately, the virus does not jump
easily from birds to humans or spread readily and
sustainably among humans. Once a fully contagious virus
emerges, its global spread is considered inevitable.
Transmission
Human infections with avian influenza viruses, though
rare, have been reported sporadically. Human infections are
primarily acquired through direct contact with infected live
or dead poultry birds or contaminated environments, such
as live bird markets.
Incubation period
2-5 days.
Diagnosis
Diagnosis is confirmed by RT-PCR. Rapid influenza
diagnostic tests (RDTs) are available, but they have lower
sensitivity compared to RT-PCR.
Treatment
Some antiviral drugs, notably oseltamivir and zanamivir
can reduce the duration of viral replication and improve
prospects of survival.
Prevention
Public health management includes personal protective
measures like regular hand washing and proper drying; good
respiratory ygiene (covering mouth and nose when
coughing or sneezing); early self-isolation; avoid close
contact with síck people; and avoid touching eyes, mouth
and nose
Vaccine
n the year 2007, a vaccine for bird flu was licensed, this
accine is for people 18 years through 64 years of age. It
is
two doses, 28 days
an inactivated influenza vaccine given in at the
art. The recipient can have pain and tenderness ill feeling.
muscle pain and general
ection site, headache, of
omeSa other vaccines were approved, but at the time current
pandemic, (as the HN, continually mutates), the
cannot be depended upon to work.
ple ofHN,
BIRD FLU
171
PANDEMIC INFLUENZA A (H,N,) 2009
(SWINE FLU)
The pandemic influenza A (H,N,) 2009 virus differs in its
pathogenicity from seasonal influenza in two key aspects.
First, as the majority of human population has little or no
pre-existing immunity to the virus, the impact of the
infection has been in a wider age range, in particular among
children and young adults. Secondly, the virus can infect the
lower respiratory tract and can cause rapidly progressive
pneumonia, especially in children and young to middle-aged
adults.
Following its emergence in March 2009, pandemic
A (H,N) 2009 virus spread rapidly throughout the world,
leading to the declaration of an inlfuenza pandemic by
WHO on 11th June 2009 (9). The world is now in
post-pandemic period. In India it causes local outbreaks.
During 2018, India reported 14,971 cases and 1,103 deaths,
a case fatality rate of 7.36 per cent (10).
Based on knowledge about past pandemics, the (H,N,)
2009 virus is expected to continue to circulate as a seasonal
virus for some years to come. While level of concern is now
greatly diminished, vigilance on the part of national health
authorities remains important, when the behaviour of H,N
virus as a seasonal virus cannot be reliably predicted (11).
On 26th September 2011 WHO has adapted a new nomen-
clature as Influenza A (H,N,) pdm09 (12).
Incubation period
The incubation period appears to be approximately 1-4
days, but could range upto 7 days.
Case definitions (13)
Suspected case : A suspected case of influenza A (H,N,)
2009 is defined as a person with acute febrile respiratory
illness (fever 2 38°C) with onset (a) within 7 days of close
contact with a person who is a confirmed case of influenza
A (H,N,) 2009 virus infection, or; (b} within 7 days of travel
to areas where there are one or more confirmed cases, or
(c) resides in a community where there are one or more
confirmed influenza A (H,N,) 2009 cases.
Probable case A probable case of influenza A (H,N,)
2009 virus infection is defined as a person with an acute
febrile respiratory illness who : (1) is positive for influenza A,
but unsubtypable for H, and H, by influenza RT-PCR or
reagents used to detect seasonal influenza virus infection, or;
(2) is positive for influenza A by an influenza rapid test or an
infiuenza immunofluoresence assay (1FA) and meets criteria
for a suspected case, or; (3) individual with a clinically
compatible illness who died of an unexplained acute
respiratory illness who is considered to be epidemiollogically
linked to a probable or confirmed case.
Confirmed case : A confirmed case of pandemic influenza
A (H,N,) 2009 virus infection is defined as a person with an
acute febrile respiratory illness with laboratory confirmed
influenza A (HN) 2009 virus infection at WHO approved
laboratory by one or more of the following tests:
a. Real Time PCR
b. Viral culture
C. Four-fold rise in influenza A (H,N,) virus specific
neutralizing antibodies.
172 PDEMIOLOGY OF cOMMUNICABLE DISEASES

Clinical features (14) Signs and symptoms ot progressive sease

Patients who present initially with uncomp
Awide clinical spectrum of disease ranging from non
influenza may progress to more severe disease D plicatea
ebrile mild upper respiratory illness, febrile influenza iike
itness (ILI), to severe or even fatal complications incu can be rapid (i.e. within z4 hours). The followingression
Some
of the indicators ot progression, which would necessitate
apidy progressive
case fatality rate is smilar to seasonal influenza i.e. abouthe
pneumonia has been described.
0.5 urgent review ol patient management. an

Per cent: however this could change (15). The clinical
features are as described below:
(a) Uncomnplicated influenza
(1) LI symptoms include fever, cough, sore throat,
rhinorrhoea, headache, muscle pain, and malaise,
but no shortness of breath and no dyspnoea. Patienis
may present with some or all ot these symptoms.
(2) Gastrointestinal illness may also be present, such as
diarrhoea and/or vomiting, especially in children,
but without evidence of dehydration.
(b) Complicated or severe influenza
(1) Presenting clinical (e.g. shortness of breath
ayspnoea, tachypnea, hypoxia) and/or radiological
Signs of lower respiratory tract disease e.g.
pneumonia), central nervous system (CNS)
involvement (e.g. encephalopathy, encephalitis),
severe dehydration, or presenting seconaary
complications, such as renal failure, multiorgan
can
tailure, and septic shock. Other complications
include rhabdomyolysis and myocarditis.
disease,
(2) Exacerbation of underlying chronic
hepatic or renal
including asthma, COPD, chronic
failure, diabetes, or other cardiovascular conditions.
(a) Symptoms and signs Suggesting oxygen impa
cardiopulmonary insutticiency: o
Shortness of breath (with activity or at rest), diffes
breathing, turning bIue, bloody or coloured sputum,
in
chest pain, and low blood pressure;
In children, fast or laboured breathing: and
Hypoxia, as indicated by pulse oximetry
(b) Symptoms and signs suggesting CNS complications
- Altered mental status, unconsciousness, drowsines or
difficult to awaken and recuring or persisten!
convulsions (seizures), conrusi10n, severe weakness, or
paralysis.
(c) Evidence of sustained virus replication or invasive
secondary bacterial intection based on laboratory testino
or clinical signs (e.g. persistent high fever and
other
symptoms beyond 3 days).
(d) Severe dehydration, manitested as decreased activity
diziness, decreased urine output, and lethargy.
Risk factors for severe disease (14)
Risk factors for severe disease trom pandemic
influenza
to date are
A (H,N,) 2009 virus intection reported for
considered similar to those risk factors
identified

(3) Any other condition or clinical presentation requiring complications from seasonal influenza. These inclute the

management.
hospital admission for clinical following groups
progressive disease. <2 years
(4) Any of the signs of (1) Infants and young children, in particular

As COVID-19 and influenza, both are respraro (2) Pregnant women

It is very important to
illnesses, they share many similarities. (3) Persons of any age with chronic pulmonary disease (eg
so as to take timely
differentiate these both diseases disease. The asthma, COPD)
manage
chronic cardiac disease es
the
appropriate action to (4) Persons of any age with
differentiating points are as follows (16)
congestive cardiac tailure)
COVID-19 INFLUENZA (e.g. diabetes
(5) Persons with metabolic disorders
nepu
1-4 days disease, chronic
Incubation period 2-14 days (6) Persons with chronic renal
conditions incu
Fever disease, certain neurological
Fever and seizure disorue
Common
symptoms Cough - Chills Eromuscular, neurocognitive,immunosuppression, w
Cough ndemoglobinopathies, or
Fatigue con
-

- Shortness of -
Fatigue due to primary immunosuppressive condition3,
h a6
Body aches HIV intection, or secondary
breath -
malignancy
- Loss of smell and pains mmunosuppressive medication or
- Loss of taste - Headache (7) Children receivingchronic aspirin therapy
- Runny or stutty nose
(8) Persons aged 65 years and older. pandemic
- Sore throat om
complications als0 bee
Body aches
A higher risk of severe infection uin thos
intluenza A (H,N,) 2009 virus
-
Less common and pains obese
particularny
symptoms
- Headache - Nausea or eported in individuals who are
diarrhoea who are morbidly obese.
- Runny or
stuffy nose Laboratory diagnosis (14) (
influenza Anmuniy
- Sore throat ndemic com for
Laboratory diagnosis of ations
Nausea or
2009 virus, especially at the beginningtimplicatio
-
diarrhoea important roCedu
Outbreak or for unusual cases, has control
Gradual Rapid
Symptom onset
- case managment, such as intectionop ns ana the diag
- Vaccines are Seasonal and swine Consideration of antiviral treatment
Vaccine and available flu vaccine and tne inappropriate use of antibiotics. urtories ineacos
laboratd
medications antiviral medication
ests can be done by specialized chain
available. olymerase
countries. Reverse transcriptase
 RiFLUEN7A 173
IRT-PCR)wilprovide
will provide the most timely and are aiso at
virus for a longer time period
and sensitive
ne niection. no may shed
risk for development of antiviral
resistant virus.
detection O mcreased
to be colecled for laboratory
Clinical Specimens
are respiratory mples. Samples Irom the upper Infiuenza vaccine
tract, including a mbination ot nasal or influenza technologies
cpirato urrently, there are three different T hese include
espia al samples, and a hroat swab are advised.
nasoplharyngeal se, to produce influenza vaccines.
suppos viral replicatioi and recovery ot recombinant technol0gies.
Recent evidence gg-based, cell-cultured, and (IfVs) are prepared
(H,N,) 2009 virus irom lower respiratory tract influenza vaccines
nandemncheal and bronchial aspirates) in 99-ased inactivated virion particies
amp palients TOm inactivated and detergent-solubilized embryonated
lower respiratory iract symploms and in these containing HA and NA proteins prepared in
presel (LATV) 1s prepared
ch samples have higher diagnostic yields than Chicken eggs. The live attenuated vaccine
Cell-cuitured
samples from the
upper respiratory tract. O atenuated, less virulent virus strains. in
are known to be cirTCulating in a vaccines are produced by growing manutacturing the intluenza virus
When influenza
viruses process.
munity, patients presenting With features of animal cells, allowing for a faster o egg
omplicated intluenza can be diagnosed on clinical and Ihough hen's eggs are not used. trace amounis
The recombinant nu
Unmiological grounds. All patienis should be instructed to PTOen may be tund in these vaccines. the HA gene and
follow-up, should they develop any signs or Vaccine is an alternative method that isolates response
return ifor proteins in order to obtain an immunogenic wtigut
sympto of progressive disease or fail to improve within use This vaccine is produced in insect cen
oi symptoms. Tne of chicken eggs.
72 hours of the onset ot HA compared
Cuures ànd contains three times the amount
Diagnostic testing. wnen available, should be prioritized witn the standard-dose preparation.
It is currently the oniy
r Datients in whom contirmation ot influenza virus infection
available influenza vaccine that is completely egg-tree ( 7).
may affect cinica management, including patients influenza viruses are included in the
considered at-risk ana/or tnose witn complicated, severe, or
wo types of human influenza A virus and intluenza b
progressive respiratory 1lness. In addition, results of
intluenza vaccine:
is reviewed annually and
diagnostic testing may also be valuable in guiding infection irus. vaccine composition on the circulating Viruses. extent
updated as needed based
control practices and managemento a patient's close
to which those viruses are spreading. and how gooa the
contacts. Under no circumstances should influenza diagnostic response was to the previous years vaccine. The World
testing delay initiation of infection control practices or tne
Health Organization makes recommendations about
antiviral treatment, iT pandemic intluenza A (H,N,) 2009 specific viruses to be included.
disease is suspected clinically and epidemiologically (14).
Several rapid influenza diagnostic tests including (so Inactivated influenza vaccine (iIVs)
called point-of-care diagnostic tests) are commercially IVs are available since 1940. Trivalent IIVs contain three
available. However, studies indicate that rapid diagnostic inactivated viruses: type A (H,N,). type A (H,N,). and
tests miss many intections with pandemic (H,N,) 2009 virus type B. Quadrivalent intluenza vaccines were iniroduced in
and, therefore, negative results cannot rule out disease, and the year 2013-2014 season. They contain the same antigens
should not be used as grounds to withhold therapy or lift as trivalent vaccines, with addition ot anotherB strain Virus.
infection control measures. increasing the likelihood for adequate protection. IIV is
administered by intramuscular or intradermal route. The
Intection control vaccine is available in both paediatric (0.25 ml) and adult
Evidence to date suggests that pandemic (H,N,) 2009 (0.5 ml) dose formulation. One dose of IV may be
virus is transmitted similarly as seasonal influenza A and B administered annually for persons 9 years of age and older.
viruses. Appropriate infection control measures (standard Children 6 months through S years ot
age receiving
plus droplet precautions) should be adhered to at all times, influenza vaccine for the first time should receive two doses
which includes strict adherence to hand hygiene with soap administered at least 28 days apart. Annual immunization is
and water or an alcohol based hand sanitizer, and to cover recommended (18).
mouth and nose with tissue or handkerchief when coughing The vaccine is about 60 per cent etfective among healthy
Or sneezing. lf ill persons must go into the community e.g. to persons younger than 65 years ot age. On vaccination, the
seek medical care, they should wear a face mask fo reduce vaccine becomes effective after 14 days. Those infected
tne Tisk of spreading the virus in the community. shortly before (1-3 days) or shortly atter immunization can
still get the disease (18). Vaccinated individuals can also get
Whenever performing high-risk aerosol-generating
infected with other strain of influenza virus for which the
procedures (for example, bronchoscopy or any procedure
use a particulate vaccine dose not provide protection (18).The immunity
Ving aspiration of the respiratory tract)
lasts fronm 6-12 months. The vaccine is 50-60 per cent
espirator (N95, FFP2 or equivalent), eye protection, gown,
efective in preventing hospitalization and 80 per cent
and gloves, and carry out the procedure in an adequately effective in preventing death among elderly persons (18).
ventuated room, either naturally or mechanicaly.
The vaccine should be stored at temperature of 2-8°C. It
ne duration of isolation precautions for hospitalized should not be frozen.
atients with influenza symptoms should be continuea to
days after onset of illness or 24 hours after the resolutior For those persons aged 65 years and older, there are
currently two influenza vacCines designed to overcome the
ver
ea
and respiratory symptoms, whichever
1s longer,

patient is in a health-care facility. For prolongea waning immune response tound in this patient population
liness with complications high-dose lIV (HD-IV) and adjuvanted IIV (allV). Both
asures should be used during 1.ePthe durationofof acute illness
acute ilness formulations are available only as a trivalent vaccine. The
HD-IIV contains tour times the HA-antigen compared with
until the patient has improved d natients standard influenza vaccines, better immune
on is needed in caring for immunosuppressed patients standard innuenza vaccines, providing a better
providing immune
174 EPIDEMIOLOGY OF COMMUNICABILE DISEASES
response and reducing clinical outcomes associated with
intluenza infection in this patient population. When
compared with patients who received standard-dose trivalent
intuenza vaccines, HD-IIV was shown to be 24% more
eftective in preventing laboratory confirmed influenza (17).
SIDE EFFECTS
Inactivated vaccines, administered by injection,
commonly cause local reactions such as soreness, swelling
and redness at the injection site, and less often can cause
tever, muscle or joint-aches or headache. These symptoms
are generally mild and do not need medical attention, and
last for 1-2 days. Fever. aches and headaches can occur
more frequently in children compared to elderly people.
Rarely, these inlfuenza vaccines can cause allergic reactions
such as hives, rapid swelling of deeper skin layers and
tissues, asthma or a severe multisystem allergic reaction due
to.hypersensitivity to certain components.
CONTRAINDICATIONS
As a general rule, inactivated vaccines should not be
administered to (19):
(1) People who have a severe allergy to chicken eggs;
(2) People with a history of anaphylactic reactions or other
life-threatening allergic reactions to any of the
constituents or trace residue of the vaccine;
(3) People with history of a severe reaction to influenza
vaccination;
(4) People who developed Guil in-Barre syndrome (GBS)
within 6 weeks of getting an influenza vaccine;
(5) Children less than 6 months of age (inactivated influenza
vaccine is not approved for this age group); and
(6) People who have a moderate-to-severe illness with a
fever (they should wait till they recover to get vaccinated).
Live attenuated influenza vaccine
Live attenuated influenza vaccine (LAlV) was approved
IIlV.
for use in 2003. contains the same influenza viruses as
It
The viruses are cold-adapted, and replicate effectively in the
are grown
mucosa of the nasopharynx. Ihe vaccine viruses
in chicken eggs, and the final product contains residual e99
protein. The vaccine is provided in a single-dose sprayer
LAIV dose
unit; half of the dose is sprayed into each nostril.
or any other preservative. LAIV is
not contain thimerosal
approved for use only in healthy, non-pregnant persons
2 to 49 years of age. Vaccinated children can shed vaccine
virus in nasopharyngeal secretions for up to 3 weeks.
LAIV is 87 per cent effective against culture confirmed
influenza in children 60-84 months old; results in
27 per
reduction
cent reduction in febrile otitis media; 28 per use.cent
in otitis media with accompanying antibiotic
SIDE EFFECTS
a spray, and
Live attenuated vaccines àre given via nasal
cause runny nose, nasal congestion, cough
can commonly low grade fever,
frequently cause sore throat,
and can less headache. Wheezing and
irritability and muscle-aches and
children receiving
vomiting episodes have been described
in
live influenza vaccines (19).
CONTRAINDICATIONS
include children
Persons who should not receive LAlv years of age and
younger than 2 years of age; persons 50
conditions, including
older; persons with chronic medical
asthma, a recent wheezing episode, reactive a rwa
or other chronic puimonary or cardiovascular conditions ase
metabolic disease such as diabetes, renal disease,
hemoglobinopathy, such as sickle cell disease: and c Or
or adolescents receiving long-term therapy with asnen
aspirin-containing therapy, because of the associator
Reye syndrome with wild-type intluenza infection of
influenza .eTSons
in these groups should receive inactivated vaccine.
As with other live-virus vaccines, LAIV should not
given to persons who are immuno-suppressed becanc
disease, including HIV, or who are receiving imm
suppressive therapy. Pregnant women should not rec o
LAIV. Immuno-suppressed persons and pregnant wOm
should receive inactivated intluenza vacine. Since 1A
contains residual egg protein, it should not be administeod
to persons with a history o severe allergy to egg or an
other vaccine component. A history of Guillain-Baro
syndrome (GBS) within 6 weeks 1ollowing a previous doso
of influenza vaccine is a precaution for LAIV
Since the spread of the epidemics of influenza Virus is
unstoppable and there is limitation of vaccine availability,
WHO recommends that all the countries should immuniza
their health care workers as the first priority to protect the
essential health intrastructure, and to prevent initiation of
nosocomial spread of disease to vulnerable patients. WHO
recommends the following groups of persons be vaccinated
according to their order of priority: la) pregnant women;
(b) individuals aged more than 6 months with one of the
several chronic medical conditions; (c) healthy young adults
between age 15-49 years, (d) healthy children; (e) healthy
adults between age 49-65 years; and (1) healthy adults aged
more than 65 years.
Treatment
Key principles for clinical management include
basic
antiviral drugs if available,
symptomatic care, early use of
for high risk populations, antimicrobials for co-intections,
and proactive observation for progression of ilnes.
Hospital care requires early supplemental oxygen therapy
To correct hypoxaemia, with saturation monitoring
at triage
caretul una
and during hospitalization, if posible,
care.
replacement, antimicrobials, and other supportive
it i
important to provide appropriate antimicrobials
tor otne
infections which also present with severe respiratory ai5a
A number of severely ill patients with pandemic (HN
disease develop respiratory distress requiring mecnal
ventilation and intensive care support.
Antiviral therapy (14) ntly
is
Pandemic influenza A (H,N,)) 2009 virus cuAl
to the neuraminidase inhibitoS tors
usceptible
MZ In
OSeltamiVir and zanamivir, but resistant to the
amantadine or rimantadine.
The following asummary of treatne
ecommendations. illness
clinical
(1) Patients who have severe or progressive
Should be treated with oseltamivir. Treatment
initiated as soon as possible. groups,
(a) This recommendation applies to all paina children
including pregnant women, and you
2 years, including neonates. ne
illness
In patients with severe or progressivc
(b) highe
responding to normal treatment reg ation
longer du
doses of oseltamivir and
 CONTRAINDICATIONS
MENINGOcocCAL MENINGITIS 181
The contraindications
Vaccination are anaphylactic
to per 100,000 population and majority cases are caused by
ertussis of disease is
ertulopathy,
ncep
a personal or strong family reaction, erogroup B strains. InAmericas, the incidence
onvulsions or similar CNS disorders: history of ne range of 0.3 to 4 cases per 100,000 population. In
any febrile
e until fully recovered: or a
reaction of the
United States, the majority cases are caused by serTOgTOU
reviously given iiple injections
vaccine /101One D,and Y. In Asia most meningococcal disease is caused by
neningococci belonging to serogroup A or C(1)
, PASSIVE IMMUNIZATION Meingococcal disesase is endemic in India. Cases of
merit ofhyperimmune globulin in neningocOccal meningitis are reported sporadically or n
pertussis a clusters. During 2018, about 3,382 cases of
rophylaxis has yet to. De established. So far, there is n
ovidence of its eiticacy in well-controlled trials (9). no meningococcal meningitis were reported in lndia with about
152 deaths. Majority of the cases were reported trom oniy
The control of pertussis by immunization is stil
ed problem. Even if the level of immunization an few states as shown in Tablel.
reaches TABLE 1
100 per cent, lt s Ppossioe tnat tne disease would not
oh eliminated because whooping cough be
vaccines have Keported cases and deaths due t
neve een claimed to be more than 90 per cent effective. nenngOcoCcal meningitis in some states in India201
References State Case Deaths
Morley, David (1973). Paediatric
Priorities in the Developing World, Andhra Pradesh 758 45
Butterworths. Madhya Pradesh 44 0
2. WHO (2018), Fact Sheet Pertussis. Uttar Pradesh 283
3 WHO (1996), The Worid iealth Keport 1996, Fighting
disease Rajasthan 44
Fostering development. West Bengal 967 80
WHO (2010), Weekly Epidemiological Record, No. 40, 1st
Oct, 2010. Uttarakhand 12
5. Govt. of India (2019), National Health Profile 2019, DGHS, Ministry Karnataka
of Health and family Welfare, New Delhi.
153
Maharashtra
6. Christie, A.B. (1980). Injectious Diseases: Epidemiology and Clinical
Practice, 3rd ed., Churchill Livingstone.
Bihar 499
7. WHO (2005), Weekly Epidemiological Record, No. 4, Jan. 28, 2005.
Delhi 46
8. Jawetz, et al, Medical Microbiology, 24th ed. 2007, A Lange Medical Jharkhand
BooR. Andman & Nicobar ZI
9. Manclark, C.R. (1981). Bul WHO, 59:9-15. Odisha 33
10. Gray, James A (198l). Medicine International, 3, 112. Haryana 335
Chhattisgarh 25
MENINGOCOCCAL MENINGITIS5 India 3,382 152
Meningococcal meningitis or cerebrospinal fever is an Source: (2)
acute communicable disease caused by N.meningitidis. It
usually begins with intense headache, vomiting and Epidemiological features
neck and progresses to coma within a few hours. The
stit (a) AGENT: The causative agent, N. meningitidis is a
meningitis is part of a septicaemic process. The fatality of gram-negative diplococci. 12 serotypes have been
typical untreated cases is about 50 per cent. With early identilied, viz. Groups A, B, C, 29E, H, I, K, L, W135, X, Y,
dragnosisand treatment, case fatality rates have declined to Z based on the structure of the polysaccharide capsule. The
less than 8-15 per cent. majority of invasive meningococcal intections are caused by
organisms of serogroups A, B, C, X, W135 and
Problem statement Y. Meningococci of these serogroups have the potential to
Distribution worldwide, occurring sporadically and in cause both endemic disease and outbreakS. In African
small outbreaks in most parts of the world. In some meningitis belt, subgroup A has been the most important
regionsS cause of disease (1). N. meningitidis is a delicate organism;
this endemic situation may alternate with devastating, it dies rapidly on exposure to heat and cold. (b) SOURCE
unpredictable epidemics. This is the case in the African
meningitis belt, which is the region in Sub-Saharan Africa
:
OF INFECTION The organism is tound in
the nasopharynx
of cases and carriers. Clinical cases present only a negligible
Stretching from Senegal in the west to Ethiopia in the east.
source of intection. More often the intection causes mild
nis region is inhabited by around 400 million people. In the or even unnoticeable symptoms of naso-pharyngitis.
African meningitis
belt the WHO definition of a 4 to 35 per cent of the normal population may harbour
meningococcal epidemic is>100 cases per 100,00 the
organism in the nasopharynx during inter-epidemic periods.
pOpulation per year. In the endemic countries, the incidence
Carriers are the most important source of infection. The
O cases, 2-10 cases and <2 cases per 100,000 mean duration of temporary carriers is about 10 months (3).
pulation per year characterize high, moderate and low During epidemics, the carrier rate may go up to
emicity respectivety. An outbreak outside the meningitis 70-80 per
cent. (c) PERIOD OF COMMUNICABILITY Until
Oet may be defined as a substantial increase n
invasiv meningococci are no longer present in discharges
from nose
gocoCcal disease in a defined population above that and throat. Cases rapidly lose their intectiousness
wnich is expected by place
and time ().- 24 hours of specific treatment. (d) AGE AND SEX : within
This is
uring recent years, several serious outbreaks affecting predominantly a disease of children and young
adults of
rous countries have occurred in tropical and temperate both sexes with highestaftack rate in
3-12 months. (e) IMMUNITY: Al ages are intants aged
Fs of other continents, viz, Americas, Asia and Europe. In
e tne incidence of disease ranges from 0.2 to 14 cases Younger age groups are more susceptible susceptible.
than older groups
 COVID-19 191
Epidemiological aspect 2.Effective isolation patients in hospitals;
of SARS
3, Appropriate protection of
medical staff treating these
Halth care workers, especially those involved in
cocures generating aerosols, accounted for 21 per cent of patients;
isolation of suspected
all cases.
Maximum virus excretion from the respiratory tract 4. Comprehensive identification and
occurs on about day 10 of illness and then declines. The SARS cases
hand-washing after
fciency of transmission appears to be greatest following imple hygienic measures such as
appropriate and well-fitted
exposure to severely ill patients or those experiencing rapid TOuching patients, use of
control measures;
linical deterioration, usualy during the second week of masks, and introduction of infection
lness. When symptomatic cases were isolated within 5 days 6. Exit screening of international travellers; of
af the onset of illness, 1ew cases of secondary transmission
7. Timely andaccurate reporting and sharing
rCurred. There was no evidence that patient transmits governments.
intormation with other authorities and/or
infection 10 days after fever has resolved.
Children are rarely affected by SARS. To date, there have
References
21 March 2003
cases ot transmission from children to 1. WHO (2003), Weekly Epidemiological Record No. 12,
heen two reported Report 2003, Shaping the future.
adults and no report ot transmission from child to child. 2. WHO (2003), World Health
No. 43, 24th Oct. 2003.
separate epidemiological investigations have not 3. WHO (2003), Weekly Epidemiological Record
Three 7, 13th Feb. 2009.
4. WHO (2009), Weekly Epidemiological Record No.
found any evidence of SARS transmission in schools. Medical Diagnosis and
of SARS has been found in 5. Stephen J. Mcphee et al, (2010), Current
Furthermore, no evidence Treatment, 49th Ed. A Lange Medical Publication.
infants of mothers who were infected during pregnancy.
International flights have been associated with the CORONAVIRUS DISEASE-19
transmission of SARS from symptomatic probable cases to
passengers or crew. WHO recommends exit screening and
other measures to reduce opportunities for further Coronavirus disease-2019 (COVID-19) is caused by
international spread associated with air travel during the SARS-CoV-2, a newly emergent coronavirus, that was first
epidemic period. recognized in Wuhan, China, in December 2019. Genetic
sequencing of the virus suggests that it is a betacoronavirus
Complications closely linked to SARS virus. It is from the family of single-
As with any viral pneumonia, pulmonary stranded RNA virus (tss RNA) with a crown like appearance
decompensation is the most feared problem. ARDS occurs in under an electronic microscope, of approximately
about 16% patients, and about 20-30% of patients require 60-140 nm diameter, contains large widely spread club or
intubation and mechanical ventilation. Sequelae of intensive petal shaped spikes. Although high temperature decreases
care include infection with nosocomial pathogens, tension the replication of the virus, it can resist the cold temperature.
pneumothorax from ventilation at high peak pressures, and It is sensitive to ultraviolet rays, and is effectively inactivated
non-cardiogenic pulmonary edema. by lipid solvents including ether (75 per cent), ethnol,
chlorine-containing disinfectants, peroxyacetic acid and
Treatment chloroform except for chlorhexidine (1).
Severe cases require intensive support. Although a number
The dynamics of SARS-CoV-2 are currently unknown,
different agents including ribavirin (400-600 mg/d and
4 gd), lopinavir/ritonavir (400 mg/100 mg), interferon type 1,
but it is speculated that it has an animal origin.
intravenous immunoglobulin, and systemic cortiocosteroids Global scenario
were used to treat SARS patients during the 2003 epidemic, the
treatment efficacy of these therapeutic agents remains In late December 2019, investigation of a cluster of
inconclusive and further research is needed. Subsequent pneumonia cases of unknown origin in Wuhan, China,
studies with ribavirin show no activity against the virus in vitro, resulted in identification of a novel coronavirus. The virus is
and a retrospective analysis of the epidemic Toronto distinct from both Severe Acute Respiratory Syndrome
Suggests worse outcomes in patients who receive the drug (5). (SARS) coronavirus and Middle East Respiratory Syndrome
(MERS) coronavirus, although closely related. Early
Prognosis epidemiological findings suggest that the virus is more
about
Ihe overall mortality rate of identified cases is 17% contagious than its predecessors. Severe Acute Respiratory
Mortality is age-related, ranging from less than in Syndrome Coronavirus-2 (SARS-CoV-2) is a newly
4.
persons under 24 years of age to greater than 50% in identified pathogen and it is assumed that there is no
persons over 65 years of age. Poor prognostic tactors existing human immunity to the virus. Every one is
nclude advanced age, chronic hepatitis B infection treated susceptible, although there may be risk factors that increase
amivudine, high initial or high peak lactate an individuals illness severity.
on
Endrogenase concentration, high neutrophil count and The disease since its first detection in China, has now
disease,
sentation, diabetes mellitus, acute kidney
on presentation. Many
spread to over 200 countries/territories. COVID-19 was
of CD4 and CD8
COuntscasesprobably go undiagnosed. Seasonality, as declareda Pandemic by WHO on 11th March 2020,
cinical resulting in shift of focus from China to Europe and North
withintuenza,is not established (5).
America and later on to the world. As such WHO advised
Prevention countries to take a whole-of-government, whole-of-society
no vaccine against SARS, the preventive approach, built around a comprehensive strategy to prevent
there isSARS control are appropriate detection and disease, save lives and minimize the effect. Countries closed
Sures for
otective measures which include: their borders against travel related activities (by air, road,
railway or sea), and lockdown was imposed to minimize the
D
ompt identification of persons with SARS,their public movements.
movements and contacts
 1922 EPDEMIOLOGY OF cOMMUNICABLE DISEASES
*

On December 14th 2020, a new strain of COVID-19 virus In Indla, the outbreak of the disease was
was reported from UR. It is speculated declar
that the new strain is epidemicand Epidemic Disease Act, 1897 was
highly contagious, about 70 per cent more transmissible leading to temporary closure of educational invoked
than
the old variant. The UK variant is now referred religi
SARS-CoV-2 VOC 2020 12/01. As to as entertainment and commercial establishments. AIls,
of 30th December 2020, visas were suspended in March 2020. On 25th March
the UR variant has been reported
in five of the six WHO the Govt. of India declared a country wide lockdown till st
regions. Another variant, 5 01Y.V2, was
December 2020, in South Africa (2). There isreported on 18th March, which was extended upto 14th April
2020 T
ot this variant causing more no clear evidence lockdown was further extended to 3rd May, then tunte
severe disease or worse outcomes. May 2020. This covers 4 phases of lockdown 17th
As of 19th February, in the
2021, about 11.08 crore cases were was followed by gradual un-lockdown in the intry. lt
reported globally with 24,53,582 country, spre:
in 6 phases (one month each) upto 30th pread
cases recovered and the recovery deaths. About 8.58 crore November 2020
reported the highest number of
rate was 77.4 per cent. USA The government divided all the districts
cases (2.85 crore, 5.05 lakh into 3 20nes
deaths). followed by Brazil (1 crore based on the spread of the virus - green,
cases and 2.43 lakh red and oranao
deaths), Russia (4.13 crore cases and 82.3 zone with relaxations appliedd accordingly. ge
The red zone was
OR (4.08 crore cases thousand deaths), further divided into containment zone
(3.53 crore cases and 83.3
and 1.19 lakh deaths), and France expanding the infrastructure, COVID-19and buffer zone. For
Dedicated Hospitals
thousand deaths) (5A). were created. They are as follows (1)
When compared globally, India's COVID Hospitals of about 1.81 1,054 Dedicated
population were amongst the cases per million lakh beds; (2) 2,681
the number of deaths per million lowest in the world. Like-wise Dedicated COVID Health Care Centres
was (3) 7,292 COVID Care Centres with 150 lakh beds:
as shown in Fig. 1 and Fig. 2 also one of the lowest, with 6.62 lakh beds. There
(3). were 9.96 lakh dedicated beds as on
The pandemic has taught the 29.5.2020 (5).
world
requires global solution". Internationalthat "global problem Maharashtra, Delhi, Kerala, Andhra
requirement of the day. Whether co-operation is the and Tamil Nadu were the worst hit Pradesh, Karnataka
in detection Creation of panic in labour states of the country.
development of vaccines or of virus or class resulted in large scale
fronts. COVID-19 has imposed action on economic and social movement of people leaving
the place of their job and
behaviour whether it is social many restrictions on our daily moving to their native place
with their families, creating
We have also discovered distancing or wearing masks. chaos.
home, and shop-from-home,
that work-from-home-study-frorm-
As on 19th February,
no visit to malls and markets are 2021, there were 1.09 million cases
workable concepts. E commerce with 156,111 deaths in
traftic. which may become a portals witnessed record the country. 1.06 million cases
permanent feature (4). recovered and the recovery rate
new cases per day were was 97.30 per cent. The
The race of vaccine has touched round about 12,000 (5A).
first batch of recipients received the finishing line and the By 19th February,
the first dose of vaccine in 2021,
December 2020. received vaccination in India. 10.1 million persons had
INDIA Aarogya Setu App: Aarogya
the Government of India Setu App was launched by
In India, the firstcase of COVID-19 was reported available in 11 languages on the 2nd April 2020, and 15
30th January 2020 in Kerala. India on including Hindi and English. It is
one of the many location-based
currently has the largest surveillance app. to let the
number of confirmed cases in Asia. users check whether
they have been in contact with intected
peaked in mid-September 2020 with The per day cases people by using location
cases, and since then it has come about 90,000 reported Smartphones. The app. is and bluetooth data trom
down to about 12,000 iOS devices. It asks available on both Android and
cases per day in February 2021. a set of questions to the user
whether they are at the risk to idenury
of the coronavirus intection.
90,000
85.853 1,800
1,753
80,000
1,600 1,571
70,000 1,521
1,400 1,276
60,000 59,948 1,141
54,106 1,200
50,000 45,781 46,978
1,000
40,000
800 -
28,355
30,000
600- 564
20,000 -
400
10,000 7895
200 112
0
ndiaRussia Italy Brazil France UK USA
oL India Russia Brazil France USA Italy UK
FIG. 1

Cases per million population amongst the lowest in the world FIG. 2
Deaths per million population amongst
(19.02.2021) the lowest in the woria
(19.02.2021)
 COVID-19 193
Mode of transmission (6)
Transmission of SARS-CoV-2 can occur gradual decline over time. The duration of RT-PCR positivity
close contact with infected through direct, generally appears to be 1-2 weeks for asymptomatic
indirect
nu nor people through persons, and up to 3 weeks or more for patients with mild to
such as saliva and respiratory
eatory droplets, which are expelled secretions
or their moderate disease. In patients with severe COVID-19
an coughs, sneezes or talks. when infected
Respiratory
disease, it can be longer (7).
-10 um in diameter whereas droplets s5 umdroplets are
in diameter
A study of the first patients in the Republic of Korea
droplet nuclei or aerosols. Respiratory showed that 9-13 secondary cases occurred among
iransmission can oCCur when droplet household contacts.
person is in close
contact
aithin 1 metre) with an infected person
who has respiratory Incubation period
Sumptoms or who IS talking. In
these circumstances,
reSpiratory droplets that include virus
can reach the mouth, 2-14days
nose or eyes of a susceptible person and can result in
infection Clinical spectrum of SARS-CoV-2 infection
Airborne transmission is detined as spread Most patients with COVID-19 predominantly havee a
of an respiratory tract infection associated. However, in a small
infectious agent caused by transmission of droplet
(aerosols)
nuclei proportion of cases, they can progress to a more severe and
that remain intectious when suspended in air over
long distances and time. Airborne transmission of SARS- Systemic disease characterized by the Acute Respiratory
CoV-2 can occur during medical procedures Distress Syndrome (ARDS), sepsis and septic shock,
that generate multiorgan failure, including acute kidney injury and cardiac
aerosols or it may also spread in indoor settings with
poor injury (7, 8). The definition of a case, a contact, and clinical
ventilation. High variability is suggested between individuals
in terms of particle emission rate speech, with presentation and risk factors are as shown in Table 1. Table 2
increased shows the progress of mild disease to a severe disease.
rates correlate with increased amplitude of vocalization
(6).
Fomite transmission is possible. Respiratory secretions Case definitions
or
droplets expelled by infected persons can
contaminate
surfaces and objects, creating fomites. Viable SARS-CoV-2 1. Suspect case (9)
virus and or RNA detected by RT-PCR can
be found on A patient with acute respiratory illness (fever and at least
those surfaces for periods ranging from hours to days,
depending on the ambient environment
one sign/symptom of respiratory disease (e.g., cough,
(including shortness of breath)), AND a history of travel to or residence
temperature and humidity) and the type of
suríace. in a country/area or territory reporting local transmission of
Therefore, transmission may also occur indirectly through
COVID-19 disease during the 14 days prior to symptom
touching surfaces in the immediate environment or objects
contaminated with virus from an infected person, followed onset
by touching mouth, OR
eyes or nose.
SARS-CoV-2 has also A patient/health care worker with any acute respiratory
been detected in other biological illness AND having been in contact with a confirmed
samples, including urine and faeces of some
patients. COVID-19 case in the last 14 days prior to onset of symptoms;
iowever, there have been no published reports of
ransmission of SARS-CoV-2 through faeces or urine. OR
A patient with severe acute respiratory
infection (fever
Period of communicability and at least one sign/symptom of respiratory disease (e.g.,
cough, shortness of breath)) and requiring hospitalization
nowing when an infected person can spread COVID-19 and with no other etiology that fully explains the clinical
amportant. Evidence suggests that COVID-19 can be.
presentation;
withnpeople. 1-3 days before their symptoms appear,
n the highest viral loads OR
as measured by RI-PCK,
erved around the day of symptom onset, followed by a A case for whom testing for COVID-19 is
inconclusive.
TABLE 1

P : Symptoms and risk factors associated with COVID-19

cal presentation Presenting signs and symptoms ot COVID-19varyt
Most persons experience fever (83-99%) cough (59-82%), fatigue (44-70%), anorexia (40-84%1.
short sof
breath(3140%), myalgias (11-35%). Othernon specificsymptoms, such as sore throat, nasalcongestion
headache, diarrhoea, nausea and vomiting, have also been reported. Loss of smell (anosmia) loS5 ofte
or

lageusia)preceding the onset of respiratory symptoms has also been reported.

Older people and immunosuppressed patientsin parficular may present with atypical symptoms such as ae
reduced afertness,reducedmobility, diarrhoea, loss ofappetite, delirium, and absence of fevern tatlgue
Symptoms such as dyspnoea,fever, gastrointestinal(G) symptoms or fatigue due to physiologic ada
pregnant women, adverse pregnancy eyents, Ouet diseases sucn as malaria, may overlap with sUmnt
COVID 19 1
Children might not have reported fever or cough as trequently as adults.
SKactors tor
vereIsease ge more than 60years (increasing with age) diabetes nypertensíon, cardiac diseaAo
Onderlying non-communicable diseases Ns) cancer hav
cerebrovascular disease, chronic kidney disease immunOsuppression and Onic lung disease
Se,
higher mortality.
Source Smoking
ce7,8)
 COMMUNICABLE IDISEASES
EPIDEMIOLOGY OF
194 TABLE 2
COVID-19 disease severity
(Table 1) meeting the case
definition for COVID-19 without evidence viral
Mild Symptomatic patients
disease pneumonia or hypoxia. breathina) h no
pneumonia (fever, cough, dyspnoea, fast but
Adolescent or adult with clinical signs of
signs
Moderate Pneumonia
pneumonia, including SpO,2 90% on room air.
of severe
disease
Child with clinical signs of non-severe
pneumonia (cough or difficulty breathing + fast breathinn and/or .
pneumonia.
chest indrawing) and no signs of severe months :250; 1-5 years:240.
Fast breathing (in breaths/min): 2 months:260;2-1l
<<

While the diagnosis can be made on clinical grounds;

chest imaging (radiograph, CT scan, ound)
and identify or exclude pulnonary complications.
may assist in diagnosis
Adolescent or adult with clinical signs of pneumonia (fever, cough, dyspnoea, fast breathing) plus ono
Severe Severe
severe respiratory distress; or SpO, < 90% on room air.
disease pneumonia the following: respiratory rate > 30 breaths/min;
followine
Child with clinical signs of pneumonia (cough or difficulty in breathing) t at least one of the ing:
tast breathing. seuere
Central cyanosis or SpO, < 90%; severe respiratory distress (e.g. grunting, very
chest indrawing); general danger sign: inability to breastfeed or drink, lethargy or unconsciousness or
convulsions.
Fast breathing (in breaths/min): <! onths:260; 2-11 months :2 50; 1-5years:2 40.
While the diagnosis can be made on clinical grounds; chest imaging (radiograph, CT scan, ultrasound)
may assist in diagnosis and identify or exclude pulmonary complications.
Critical Acute respiratory Onset : within 1 week of a known elinical insult (i.e. pneumonia) or new or worsening respiratory
disease distress syndrome symptoms.
(ARDS) Chest imaging: (radiograph, CT scan, or lung ultrasound): bilateral opacities, not fully explained by
volume overload, lobar or lung collapse, or nodules.
Origin of pulmonary filtrates: respiratory failure not fully explained by cardiac failure
Need objective assessment (e.g. echocardiography) to exclude hydrostatic cause of
or fluid overload,
no risk factor present. infiltrates/oedema if
Oxygenation impairment in adults:
Mild ARDS : 200 mmHg< Pa0,/FiO, 300 mmHg (with
s
Moderate ARDS : 100 mmHg< PaO/FiO,s 200 mmHg (with
PEEP or CPAP 2 5 cmH,0).
PEEP 25 cmH,O).
Severe ARDS: Pa0/FiO,S 100 mmHg (with PEEP 25
Oxygenation impairment in children: note Ol and
cmH,O).
wean Fi0, to maintain SpO,s 97% to calculate OSI. Use OI when available. If PaO, not available,
OSI or SpO,/FiO, ratio:
Bilevel (NIV or CPAP) 25 cmH,O
-
via full face mask: PaO,/FiO,s 300 mmHg
- Mild ARDS (invasively ventilated) : or Sp0,/FiO,s264.
4 S OI < 8
-
Moderate ARDS(invasively ventilated):8OIor 5 OSI < 7.5.
-
or
Severe ARDS (invasively ventilated): Ol216 < 16 7.5sOSI < 12.3.
Critical or OSI2 12.3.
Sepsis Adults : acute life-threatening
disease proven infection. Signs of organ organ dysfunction caused by a
dysfunction include: altered dysregulated host response to suspected or
mental
fast heart rate, weak pulse, status,
Oxygen saturation, reduced urine output, difficult or fast breathing. low
skin mottling, laboratory cold extremities or low blood pressure,
evidence of coagulopathy,
hyperbilirubinaemia. thrombocytopenia, acidosis, high lactate, oor
Children : suspected or proven
infection and 2 age-based
(SIRS) criteria,' of which
one must be abnormal2temperature systemic inflammatory response syndrome
Septic shock Adults: persistent hypotension or white blood cell count.
MAP 265mmHg and serum despite volume resuscitation,
lactate level >2 mmol/L. requiring vasopressors to maintain
Children: any hypotension (SBP
following: altered mental status; < 5th centile or> 2 SD below
bradycardia or tachycardia normal for age) or twoor three ot
heart rate < 70 bpm or>150 bpm in children); prolonged (HR<90 bpm or > 160 bpm in intants an
tne
breathing; mottled or cool capillary
skin or petechial or refill (> 2 sec) or weak pulse;
hyperthermia or hypothermia. purpuric rash; high lactate; reduced ias
Other complications that have been urine outpu
embolism, acute coronary syndrome,described in COvi-19 patients include acute,
for COVID-19 patients, and acute strOke and life-threatening conditions
appropriate diagnostic anddelirium.
treatment
Cinical suspicion for these such as: acute pulmonary
complications should be heightened
a If altitude is higher than 1000 m, protocols available. wnen ca
b When PaO, is not available, then thecorrection factor should be calculated
c Oxygenation Index (OI) is anSpO/Fi0,s 315 suggests ARDS (including in as follows: PaO./FiO,
invasive
in paediatric patients. It is calculated measurement of the severity of hypoxaemic non-ventilated patients). x barometric pressure/760.
divided by the partial pressure of astollowS: percentage orraction ot respiratory failure
shown to be a reliable arterial oxygen tin mmig).OXygen inhaled oxygen multiplied and may be used to predict outco mes
surrogate marker saturation by the mean airway pressure
measured by pulse oximetry (SpO,) in theofl
d The SOFA score ranges from 0 Ol
in chilaren and
equation.
index (OSI) is a non-invasive
adults with respiratory
failure. measurement i
OSI replaces PaO, with oxygen and nas o as
n
coagulation (low platelets); to 24 and incudes points related to Six organ saturauo
by Glasgow Coma Scale); Iiver {hign dilron caraOvascar systems: respiratory
(hypoxaemia defined by low
and renal (low urine output Or nign (nypotension); central nervous svstem
of 22 points. Assume the baseline Pau
score is 0 it data are not creatinine). Sepsis is defined (low
e SIRS criteria: abnormal
temperature(> 38.5 or available. bu increase in level
an of consciousness den
the sepsis-related SOFA SCore
need for mechanical ventilation; abnormal 3b tachycardia for age or
ABBREVIATIONS :
BP blood pressure; bpm
white blood cell count tor bradycardia
age or > 10% bands for age if<l year; tachypnoea 1or ag
FiO. fraction of inspired oxygen; MAP mean beats per minue A COntinuous
using Sp0,; PaO, partial pressure artertal positive airway pressure:
SIRSsystemic inflammatory arterial oxygen, F Pressure oninvasive ventilation; CT computed tomogra
response syndrone, dorA poSIve end-expiratory pressure; OI Oxygenation Index:
SBP sustolic blood pressure: OSI Oxygenationi
SEguenuai organ talure SD standard deviation
Source: (7, 8) assessment; SpO,
oxygen saturation.
 Laboratory confirmed case (9
tvidieiiiisipnrne
COVI9 195
2,
person with laboratory confirmation Oropharyngeal suab (e.g. throat swab Tilt patient's
A of COVID-19 head back 70 degrees. Rub swab over hoth tonsillar pillars
infection, irrespective clinical signs and symptoms.
and posterior oropharynx and avoid touching the tongue
feeth, and gums. Use only synthetic fiher svsabs with plastic
Definition of contact
shafts. Do not use calcium alginate suwabs or swabs with
A contact is a person hat is involved in any of wOoden shafts. Place swabs immediately into sterile tubes
the
following containing 2-3 ml of viral transport media.
Draviding direct care without proper personal
protective Combined nasal & throat swab Tit patient's head back
equipment (PPE) for COVID-19 patients T0 degrees. While gently rotafing the swab. insert swab less
Stauing in the same close environment of a COVID-19 than one inch into nostril (until resistance is met at
patient (including workplace, turbinates). Rotate the swab several times against nasal wall
classroom, household, and repeat in other nostril using the same swab. Place tip ot
gatherings).
the swab into sterile viral transport media tube and cut otf
Travelling together in close proximity (1 m) with a the applicator stick. For throat swab. take a secand dry
sumptomatic person who later tested positive for polyester swab, insert into mouth. and swab the posterior
COVID-19. pharynx and tonsillar areas (avoid the tongue). Piace tip of
Swab into the same tube and cut off the applicator tip.
High risk contact Nasopharyngeal swab: Tilt patient's head back 70 degrees.
.Touched body fluids of the patient (Respiratory tract Insert flexible swab through the nares parallel to the palate
secretions, blood, vomit, saliva, urine, faeces) (not upwards) until resistance is encountered or the distance
is equivalent to that from the ear to the nostril of the patient.
Had direct physical contact with the body of the patient Gently, rub and roll the swab. Leave the swab in place for
including physical examination without PPE.
several seconds to absorb secretions before removing.
Touched or cleaned the linens, clothes, or dishes of the
patient. Clinicians may also collect lower respiratory tract samples
when these are readily available (for example, in
Lives in the same household as the patient. mechanically ventilated patients). In hospitalized patients in
Anyone in close proximity (within 3 ft) of the confirmed Dedicated Covid Hospitals (severe cases with confirmed
case without precautions. COVID-19 infection), repeat upper respiratory tract samples
Passenger in close proximity (within 3 ft) of a should be collected to demonstrate viral clearance.
conveyance with a symptomatic person who later tested
positive for COVID-19 for more than 6 hours.
Nucleic acid amplification testing (NAAT) for
SARS-CoV-2
Low risk contact Reverse transcriptase polymerase chain reaction (RT
Shared the same space (Same class for school/worked in PCR)-based diagnostic tests (which detect viral nucleic
same room/similar and not having a high risk exposure acids) are considered the gold standard for detecting current
to confirmed or suspect case of COVID-19). SARS-CoV-2 infection. More recently, NAATs have included
a variety of additional platforms (e.g.. real-time loop
iravelled in same environment (bus/train/flight/any mediated isothermal amplitication). Clinically, there may be
mode of transit) but not having a high-risk exposure. a window period of up to 5 days after exposure before viral
nucleic acids can be detected. However, false negative
Diagnosis of COVID-19 NAAT results can also occur outside of this 5-day window.
esting strategies for Covid-19 diagnosis There are two Therefore, a single negative test resuit does not completely
pes of testings for SARS-CoV-2. (1) Diagnostic testing: It is exclude SARS-CoV-2 infection in people with a high
ended to identify current infection at the individual level likelihood of iníection based on their exposure history and/
or their clinical presentation, and repeat testing using a
pertormed when a person has signs and symptoms NAAT should be considered.
sstent with COVID-19, Or when a person 1S
tomatic but has recent known or suspected exposure, SARS-CoV-2 poses several diagnostic challenges,
o identify infected including potentialy discorcdant shedding of virus from the
persons creening testing: It is intended to upper versus the lower respiratory tract. Due to the high
who are asymptomatic and without known or
exposure to specificity of NAAT, there is no need to obtain a lower
oed SARS-CoV-2. Screening festing 1s
respiratory tract sample to diagnose COVID-19 when a
Ormed to identify
that persons who may be contagious so recent onset of COVID-19-compatible
ures can be taken.to prevent further transmission patientwith
symptoms has a positive NAAT On an upper respiratory
the disease
sample.
MOLECULAR
TEST
Antigen testing for SARS-CoV.2
Hesni
ry
ALower sample collection method (7) When compared with RT-PCR-based tests, antigen-based
diagnostic tests (which detect Viral antigens in nasal or
iratory tract nasopharyngeal swabs, also called RDI} are less
nchoalueolar layage, tracheal aspirate, sputum sensitive
but have a similarly high speciticity. Antigen tests perform
ect 2-3 mL into a sterile,leak-pro, e best early in the course ot symptomatic SARS-CoV-2
SputumOection cup or sterile dry container infection, when the viral load is thought to be highest.
When
PDer respiratory a person who is strongly suspected of having SARS-CoV-2
Nasopharyngeal iract infection receives à negative result on an initial antigen test.
swab and oropharyngeal
 DISEASES
EPIDEMIOLOGY OF cOMMUNICABLE
196 hours in the
be performed within the first 24 suspect
repeat testing using a NAAT should be considered. every 24/48 hours and can be useful for patient follnd
low cost and
Advantages of antigen-based tests are theirimmediate results choice of the setting of mecnanical ventilation, and for
of
rapid turnaround. The availability point-of
indication of prone positioning.
the
option for
makes antigen-based tests an attractive where
care testing in high-risk congregate settingstests also Laboratory examinations (10)
is critical. Antigen-based
In the early stage the disease, a
Preventing transmission ot normal or decro
ecreased
persons witn
allow tor repeat testing to quickly identitylimited data to total white blood cell count
(WBC) and a decrease
SARS-CoV-2 infection. Currently, there are lymphocyte count can be demonstrated. Interest
tests to detect or exclude
guide the use of rapid antigen persons or to lymphopenia appearS to be à negative
prognostic tactor
SARS-CoV-2 infection in asymptomatic enzymes, lactate dehydrogenas
was previously contirmea Increased values of liver
determine whether a person whostill infectious. (LDH), muscle enzymes, and CTeactive protein can
be

to have SARS-CoV-2 infection is

detected.
of a normal procalcitonin
Serologic or antibody testing for diagnosis
value
- Unless a bacterial overlap,
SARS-CoV-2 s found.
neutrophil-to-lymphocyte ratio (NLR),
for SARS-CoV-2 that The elevated
Unlike NAATs and antigen tests (neutrophil count divided by
virus, serologic or antibody
tests derived NLR ratio (d-NLR)
detect the presence of the persons with recent or prior the result of WBC count
minus neutrophil count), and
are intended to identify or platelet-to-lymphocyte ratio, can be the expression of the
it may take 2l days of these indices is
an
SARS-CoV-2 infection. Becauseseroconversion or detection inflammatory storm. The
correction
trend.
onger after symptom onset for antibodies to expression of a tavourable
Immunoglobulin lgM and/or lgG
as the sole basis
O serologic testing
SARS-CoV-2. The use of SARS-CoV-2 infection is not -Increased D-dimer. increased, blood
patients, D-dimer value is laboratory
acute tests for In critical persistently, and
for diagnosing NAATs and antigen ymphocytes decrease amylase,
recommended. Given that yield false negative results, alterations of multiorgan imbalance
(high

SARS-CoV-2 occasionally as an
in some settingsstrongly coagulation disorders
etc.) are found.
been used
serologic tests have test for patients who areserology in patients with severe
disease, collect blood
antimicrobial
additional diagnostic
SARS-CoV-2 infection.
Using
antibodies
For COVID-19
ideally prior to
initiation of
intections
culture,
suspected to have NAAT to detect lgG or total maximizes the for blood intection with other
respiratory
found in
COVID-19
combination with a onset of symptoms therapy. Dual fungal) have been
weeks after intection (10). (viral, bacterial and on local epidemiology and cinical
3 to 4 to detect past Depending aefiologies, eg,
and specificity
sensitivity patients.
for other
potential
dengue
rever,
symptoms, fest respiratory viruses, malaria,
IMAGING influenza, other appropriate (7)
CHEST
typhoid tever as
examination pneumonia, COVID-19 chain o
Chest X-ray manifests itself as diagnostic Management of to break the o
disease the
fundamental role in radiographic containment phase, suspected,
Since the has a Standard In the COVID-19, patients with managed at
radiological imaging follow-up. sensitivity in can be
management, and chest has a low transmission of isolated. Cases Community Healn
the disease are Units,
process, initial stages of
H0splldiby
of the Conirmed First Referral District
examination (X-ray) in the In the Care
lung changes completely negative. X-ray ovid (CHC), Sub-district
Centre, Hospitals,
identitying earlystage, it can be the, chestalveolar Centres Colleges. including tnar
At this intection, multifocal Medical taken aay
stages of and
disease. clinical history is followed up raie
is
advanced shows bilateral the
complete
Detailed
more to patient (SpO,.
examinafion
generally confluence up associated, CO-morbidities. The oxygen
saturation symptoms
to
which tend effusion can be vitals and and
opacities, lung. Pleural emperature, monitored for signs
urgent
prompt should be mon
rererrd. rad
opacity of the Snouid be should
tomography computed complications that severe illness deterioratio.
computed method, chest (HRCT), tactors for risk of ceure in
the CT Vitn risk possible symptoms
Chest sensitivity of high-resolution CovID-19 given the 5u or presu
high OSeg, any worsening persistent pain ano
Given the (CT), in particular the study ofnon-specitic develop breathing, taceups, immedia
diately
tomography in
choice stages. Several most Onrusion, difticulty
coloration of should be Dedicateu
method of the initial can be found. Theglass" chest,
bluish
output etc.), they Centre or
HealthCOVID-19 Shoua
is the even in patterns bilateralgroundpatchy the urine Covid
pneumonia, areas withgreater ecreasedto a Dedicated
findings and are
multirocal
consolidation
HRCT findings peripheral/subpleural with Other amited
with mild cinica d
Childrensymptoms of include
in
r
and ioSpital.
common associated with lower lobes.
area
OVIa signs and
of monitorea tor re-evaluation.
These
(for
intants: grui
areas and focal and breathing chest pai
is a urgent shallow interacting
(GG) mainlyposterior regions which consolidation, requing lips or
face,
t d
distribution, sign or blue awakenno 1as.
the
involvement of "reversed
are the a peripheral
halo
ringwith
calcifications,
Iymphadenopathies
nTast
to
breast-feed),
naoliy new
pressure,
confusion,
inability to
aow manageme
drink or keep for
du ntof
findings by
delimited cavitations, inability to guidance
when awake, clinical
is as
showni
GGfindings of (10). for
suspect/confirmed case
algorithm
the
the pleural elfusion evolution oflung" An
COVID-19
and ultrasound "white
evaluating theup to should
allow pattern
consolidations. It
LungOltrasound can
interstitial
focal subpleural
from aoften of
disease,
evldence
with
 COVID-19 197
COVID-19 Suspect/Confirmed case

Stratification on the basis of disease severity

Mild Moderate Severe

(Fever and/or uncomplicated Pneumoina with no signs of severe disease Respiratory distress requiring mechanical
upper respiratory tract RR224 min OR SpO, <94% on room air ventilation (non-invasive & invasive)
infection) without dyspnoea RR230/min OR SpO, <90% on room air
or hypoxemia.

Admit to COVID Care Center Admit in DCHC/Dedicated COVID Health Center Admit in DCH/Dedicated COVID Hospital

.Contact and droplet Oxygen Support Oxygenation

precautions
Strict hand hygiene
Symptomatic management
with adequate hydration
Tab HCQ (400 mg BD x
1
day f/b 400 mg OD x
4 days) may be considered|
in patients with high- risk
features preferably after
shifting to DCHC/DCH
Referral to DCHC/DCH is
indicated if: RR z 24 min
OR SpO,< 94%
on room air.
|1. Very mild/
pre-symptomatic/
asymptomatic cases can
be considered for home
isolation subject to
fulfillment of conditions
stipulated in guidelines
Target Sp0,:92-96% (88-92% in patients with COPD) .Cautious trial of CPAP with oro-nasal
Preferred device for oxygenation Non-rebreathing
:
mask/NIV with helmet interface/HFNC,
if work of breathing is low. Consider
face mask (if HFNC or simple nasal cannula is used,
intubation if work of breathing is high/
N.95 or surgical mask should applied over it)
not tolerating NIV
Awake proning may be used in patients who continue
to have hypoxemia despite oxygen > 4L/min, .Lung protective ventilation strategy by
if no contraindications
ARDS net protocol
be considered when
Prone ventilation tohypoxemia
Anticoagulation there is refractory
. Prophylactic dose of LMWH/UFH, if no Anticoagulation
contraindications (e.g. enoxaparin 40 mg daily SC)3 or
.High dose prophylactic UFH LMWH
Corticosteroids (e.g. enOxaparin 40 mg or U.5 mg/kg
-IV Methylprednisolone 0.5-1 mg/kg or BD SC) it not at high risk of bleeding
Dexamethasone 0.1-0.2 mg/kg for 3-5 days Corticosteroids
Antivirals IV Methylprednisolone 1-2 mg/kg or
.Tab HCQ (400 mg BD x day f/b 400 mg OD x 4 days)
1 Dexamethasone 0.2-0.4mg/kg for 5-7 days
if no contraindications and after assessment of ECG for Ifsepsis/septic shock: Manage as per existing
QT interval, CRP, D-dimer & Ferritin every 48-72 protocol & local antibiogramn
hourly (if available), CBC with differential count, Use sedation and nutrition therapy as per
absolute lymphocyte count, KFT/LFT to be done daily. existing guidelines
|Investigational Therapies |Investigational Therapies7

Testing: While attending suspect cases, as per above protocol based on clinical assessment testing|| Discharge: After clinical improvement,
as
shall be resorted to and if negative, manage in non-COVID tacility according to clinical diagnosIs. | discharge per revised discharge policy!

Low molecular
3. LMWH:heparin | 5. Risk of bleeding : use validated score for
2. High-risk patients for severe disease include: weight if no:
assessing bleeding risk (e.g. HAS-BLED score),
Age 60 years or more contraindication or high risk Use D-dimer and SIC score for further risk
Hypertension, DM (diabetes mellitus) & other of bleeding; UFH: stratification (SIC score 4 portends high
immunocompromised states Unfractionated heparin thrombotic risk),
Cerebrovascular disease and obesityg Follow AHA/ESC and ISTH guidelines in case
(BMI>25 kg/m) 4. Higher chances of
NTV failure patient is on anti-platelet agents.
Chronic lung/kidney/liver disease
oerore prescribing any of these therapies besides takina
hvestigational therapies (Informed and shared decision making is essential note of
nra-indications as mentioned in the detalled guidelines).
6 Inj Remdesivir
200 mg IV on day followed by 100 mg daily
I IV for next.4 dayslotal days therapy), in moderate to severe disease on
contraindications,
or mechanical ventilation (preferably early disease), no
if
en
Use of convalescent plasma (200 ml single dose, may be repeated alter z4 hrs, may be considered in moderate to severe nat
Persistent or increasing oxygen requiremen
7 Inj
Tocilizumab 8mg/ka (max. dose S00 mg once; usual dose 400 mo may be censldered no contraindications) inin pati
oxygen requirements despite if
use of corticosteroids with raicd ns) patients moderate

ee
Can aisease with progressively increasing occurs the tirst dose.
with
repeated after 12 to 24 hours If no Improvement

; i FIG. 3
Source
Analgorithm forelinlcal guldance for management for COVID-19suspected/confirmed cases (lndia)
(7)
 198 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

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

Prevention of complications
3. Tocilizumab (off label)
Implementation of the following may be considered in patients
interventions can with moderate disease with
prevent complications associated with progressively increasing oxygen
critical illness. requirements and in mechanically ventilated
improving despite use of steroids. Long patients not
Investigational therapies (7, 11) term safety data in
COVID 19 remains largely
At present, use of these therapies is unknown. Special considerations
available evidence. As the situation based on a limited before its use include: presence
markers (e.g., CRP, Ferritin, of raised inflammatory
data become available, the evidence evolves, and when more IL-6); patients should be
incorporated, and recommendation will be accordingly carefully monitored post
Tocilizumab for secondary
these drugs should only be used in a upgraded. Currently, infections and neutropenia;
and the drug is contraindicated
patients: defined subgroup of in PLHIV, those with active infections (systemic bacteria
fungal), tuberculosis, active hepatitis, ANC<2000/mm and
1. Remdesivir (under emergency use authorization) Platelet count<1,00,000/mm3.
be considered in patients with moderate mayy
Bmg/kg (maximum 800 The dose of Tocilizumab 1s
disease (those on
oxygen) with none of the following
contraindications: AST/ 100 ml NS over 1 hour; mg at one time) given slow
ALT>5 times upper limit of 12 to 24 hours if dose can be repeated once
normal (ULN); severe renal needed.
impairment (i.e., eGFR<30ml/min/m2
or need for
hemodialysis); pregnancy or lactating Repurposed or off-label
(<12 years of age). The recommendedfemales; and children therapies (7, 11
day 1 followed by 100 mg IV daily for 4 dose is 200 mg 1V on Hydroxychloroquine This
days (total 5 days). In vitro activity against drug has demonstae
2. Convalescent plasma (off label) SARS-CoV2 and was shown
in several small single center suoib
clinically beneficial
in patients with moderate disease may be considered
who are not improving though with significant
(oxygen requirement is progressively arge observational limitations. Nonetheless Sevex
increasing) despite use studies with severe methodoo
ofsteroids. Special pre-requisites while limitations have shown
convalescent plasma include: ABO considering clinically meaningful no effect on mortality or
compatibility and cross outcomes.
matching of the donor plasma;
neutralizing
plasma should be above the specific threshold.titer of donor
behind its use remains
should only be used
As such, the evidence
limited as with other drugs as
not available, plasma IgG titer If the latteris patients while awaiting after shared decision making 3
(against withtin
1:640 should be used; recipient shouidS-protein RBD) above the case with other the results of ongoing studies
for several hours post transfusion for be closely monitored early in the antivirals, this drug should
be used a
adverse events; and use should be any transfusion related disease course as
posible to
IgA deficiency or immunoglobulinavoided in patients with
meaningtul effects
severe disease. and should be avoided in achieve a
patients
variable ranging from 4 to 13 ml/kg allergy. The dose is An ECG should ideally
be
to measure QTc intervaldone beto
prescribing the drug
dose given slowly over not less than 2 (usually 200 ml single avoided if QTc is (and FiC
hours. day 1 followed >500 ms). The dose is 400 mg
by 400mg daily for next BD on
4 days.
 COViD-19 199
ill
. all contacts with the
he permission
The to use azithromycin in combination with Perform hand hygiene following Dry hands with towel.
hydroxychloroquine to treat patients with severe persons. Refer to page 145 for details. by all,
coronavirus infection has been rolled back (11). . Respiratory hygiene should be
practiced
especially ill person. nose
Home care for COVID-19 patients 8. Discard the material used to
cover the mouth and
To ensure both safety and quality of health care of the or clean them appropriately.
fluid, particularly oral
natient, isolation and monitoring is preferable in a hospital 9. Avoid direct contact with body
etting. However, for several reasons, in situations when
set and nasal secretions.
inpatient care is not available or in case of informed refusal touched surfaces such as
10. Clean and disinfect frequently bedroom furniture
for hospitalization, patients with mild symptoms and without
bedside tables, bedframes, and other containing diluted
chronic lung, heart or renal diseases may be cared for in the daily with household disinfectant
home environment. The same principle of care applies to bleach.
sumptomatic patients no longer requiring hospitalization. 11. Clean bathroom and toilet surfaces
once daily.
The patient and family should be provided with ongoing 12. Clean clothes and bed clothes, bath and hand towels etc.
support, education and monitoring. They should adhere to at home until
13. Persons with symptoms should remain
the following recommendations (12) based on either clinical
their symptoms are resolved RT-PCR tests at
1. Place the patient in a well-ventilated single room. and/or laboratory findings (two negative
2. Limit the number of caretakers of the patient, ideally least 24 hours apart).
contacts
assign one person who is in a good health without risk 14. All household members should be considered
for respiratory
conditions. No visitors. and their health should be monitored breathing.
if infection, fever, cough, sore throat, difficult
3. Household members should stay in a different room or,
that is not possible, maintain a distance of at least
1 m 15. Use of pulse oximeter to monitor oxygen saturation.
measures
from the ill person (e.g. sleep in a separate bed). Pulse oximeter: It is a compact portable device, signal
(SpO,), heart rate and
4. Limit the movement of the patient and minimize shared arterial blood oxygen saturation
SpO, 30 to 100 per cent
space. Ensure that shared spaces (e.g. kitchen, strength. Measuring range
beats
1 per cent), heart rate 20 to 250
bathroom) are well ventilated (e.g. keep windows open). (minimum graduation
-

per minute (minimum graduation beat per minute).

1
5. The caregiver should wear a medical mask fitted tightly
to the face when in the same room with the ill person. Revised discharge poliçy for hospitalized patients
If
Masks should not be touched or handled during use.
the mask gets wet or dirty with secretions, it must be The recommendation of Government of India on the
changed immediately. Discard the mask after use and discharge policy is summarized and is as shown in the
algorithm in Fig. 4.
perform hand hygiene after removal of the mask.

Confirmed COVID-19 case

Moderate** Severe**
Very Mild/ Mild/
Pre symptomatic"

resolved within Symptoms not Discharge only after

Discharge after 10 days Fever resolved and demand
3 days .Clinical recovery
Ot symptom onset and and oxygen saturation
of oxygen therapy
no fever for 3 days continues .Patient tested
maintained without support negative once by
RT-PCR (after
Discharge after 10 days of Discharge only after resolution of
Symptomonset Resolution of symptoms)

Absence of fever without clinical symptoms

antipyretics Ability to maintain
Resolution of breathlessness oxygen saturation
No oxygen requirement for 3 consecutive days

NO RT-PCR test required before discharge

will be advised to isolate himself at home **Including

At the time of discharge, the patient
and self-monitor their health for
further 7 days immunocompromised
(HIV patients, transplant
as per guidelines
Clinical categorization of patients recipients, malignancy)

FIG. 4

Revised discharge policy for COVID-19

Source:114)
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES
200 facility seting
3. In health-care
Post COVID-19 management protocol (15) (physical/telephonic) should h-
The first follow-up visit
After acute COVID-19 illness, recovered patients may within 7 days after discharge,
prelerably at the hospita
continue to report wide variety of signs and symptoms Ireatment.
in where he/she underwent
including fatigue, body ache, cough, sore throat, difficulty .Subsequent trealment/follow-up
visits may be with the
holistic approach is required for tollow-Up practilioner/medical
breathing etc. A
nearest qualified allopathic/AYUSH
care and well-being of all post-COVID-19 recovering facility of other systems of medicine. Poly-therapy is to
1or
patients. The recovery period is likely to be longer drug-drua
form of the disease and be avoided due fo potenlial tor unknown
patients who suffered more severe interaction, which may lead to Serious Adverse Events
those with pre-existing illness. Adverse Effects (AE).
(SAE) or
isolation, if theu
POST-COVID FOLLOW-UP PROTOCOL The patients who had undergone home
complain of persisting symptoms, will visit the nearest
1. At individual level health facility.
Continue COVID appropriate behaviour (use of mask, Severe cases requiring critical care support will require
hand and respiratory hygiene, physical distancing). more stringent follow-up.
Drink adequate amount of warm water (if not contra
indicated) Public health surveillance for COVID-19 (13)
Take immunity promoting AYUSH medicine, to be The aim of national surveillance for COVID-19 is to
practiced and prescribed by a qualified practitioner of enable public health authorilies to reduce transmission of
AYUSH. SARS-CoV-2, thereby limiting associated morbidity and
If health permits, regular household work to be done. mortality.
Professional work to be resumed in graded manner. The objectives of COVID-19 surveillance are to
Mild/ moderate exercise
Enable rapid detection, isolation, testing, and
Daily practice of yogasana, pranayama and management of cases
meditation, as much as health permits or as prescribed.
Detect and contain clusters and outbreaks, especially
Breathing exercises as prescribed by treating among vulnerable populations
physician.
ldentify, follow-up and quarantine contacts
Daily morning or evening walk at a comfortable pace
as tolerated. Guide the implementation and adjustment of targetted
control measures, while enabling sale resumption of
Balanced nutritious diet, preferably easy to digest freshly economic and social activities
cooked soft diet.
Evaluate the impact of the pandemic on health care
Have adequate sleep and rest.
systems and society
Avoid smoking and consumption of alcohol.
Monitor longer term epidemiologic irends and evolution
Take regular medications as advised for COVID and also
of SARS-CoV-2 virus and monitor trends in COVID-19
for managing comorbidities, if any. Doctor to be always
deaths
informed about all medicines that the individual is taking
(allopathic/AYUSH) so as to avoid prescription Contribute to the understanding of the co-circulation of
interaction. SARS-CoV-2 virus, iníluenza and other respiratory
monitoring at home-temperature, blood viruses, and other pathogens.
Self-health
pressure, blood sugar (especially, if diabetic), pulse Surveillance approaches
Oximetry etc. (if medically advised)
If there is persistent dry cough / sore throat, do saline
Most countries need significantly strengthened surveillans
COVID-19,
gargles and take steam inhalation. The addition of herbs/ capacities to rapidly identify and care for cases of
trace and quarantine their contacts and monitor disease trends
spices for gargling/steam inhalation can help. Cough surveillance for COv
over time. Comprehensive national
medications, should be taken on advice of medical will require the adaptation and reinforcement ot existlng
doctor or qualified practitioner of Ayush.
national systems, where appropriate, and the scale-upo
Look for early warning signs like high grade fever, additional surveillance capacities, as needed. Dg
breathlessness, SpO, <95%, unexplained chest pain,
1echnologies for rapid reporting, contact tracing and dalda
new onset of confusion, focal weakness. management and analysis may support these capacilies
2. At the level of community Robust comprehensive surveillance, once in place, sto
0e maintained even in areas where transmission has been
.Recovered individuals to share their positive experiences
with their friends and relatives using social media, Suppressed or controlled, even if there are few or no cases. lts
oe
community leaders, opinion leaders, religious leaders for critical that new cases and clusters of SARS-CoV-2 intection
creating awareness, dispelling myths and stigma. detected rapidly before outbreaks or widespread transmissto
Take support of community based self-help groups, civil Occurs. ngoing surveillance for COVID-19 is also important
to understand longer-term epidemiological trends, Such
society organizations, and qualified professionals for
incidence and mortality among different age groups. which
covery and rehabilitation process (medical, social,
Population groups are at higher risk for severe disease anu
nd
occupational, livelihood).
death, and potential epidemiological changes over fime
Seek psycho-social support from peers, community
health workers, counsellor. lf required seek mental health Key actions for comprehensive COVID-19 surveillance
support service. include:
existing
Participate in group sessions of Yoga, Meditation etc. -Use, adaptation and strengthening of
while taking all due precautions like physical distancing. surveillance systems
 COVID-19 201
rengthen laboratory and testing capacities
adaptation and enhancement ot public health work- Number of confirmed deaths
Number of probable deaths
to carry out case inding, contact tracing and
Number of individuals hospitalized
(confirmed and
testing
COVID-19 as a mandatory notifiable disease probable)
Inclu
Number discharged (confirmed and probable)
Implement immediate reporting
Number of health care workers infected
(contirmed +
Fstablish systems to monitor contact tracing activity. count
probable) as a subset of total cases
due to
t is important to maintain routine syndromic surveillance Number of health care workers who died of total
other intectious diseases, especially those caused by COVID-19 (confirmed + probable) as a subset
for
respiratory pathogens, Such as
influenza and respiratory death count
suncytial virus, through surveillance for influenza-like-illness Number of persons tested
t severe acute respiratory infection (SARI), atypical Number of persons tested by PCR
pneumonia and unexplained fever, with sampling and Confirmed + probable cases by age group and sex
jaboratory testing of all or a subset of cases. This is critical Confirmed + probable deaths by age group and sex
for understanding trends in other diseases with similar
presentations to guide appropriate public health Categories for transmission pattern (16)
Dreparedness and clinical management. the following categories to
WHO recommends using
Essentialsurveillance for COVID-19 describe transmission patterns at national and sub-national
levels to guide decisions for preparedness, readiness and
Surveillance systems should be geographically response activities. The definitions of categories are as
comprehensive, and surveillance for vulnerable or high-risk shown in Table 4.
populations should be enhanced. This will require a
combination of surveillance systems including contact Prevention of the disease
tracing for all levels of the health care system, at the Do gaj ki doori, mask hai jaroori" is the slogan of the
community level, in closed residential settings and in other day. Althogh the vaccine is now available in India, it is
vulnerable groups. Table 3 shows how surveillance systems critical that people should continue to follow all the "COVID
can be combined across different sites. Appropriate Behaviour". They should use mask, maintain a
physical distance of at least 6 feet when in public place, not
Global surveillance touch nose, eyes and mouth, cover mouth and nose while
The objectives of the global surveillance are as follows: coughing and sneezing and avoid spitting in open, prompt
testing on observing symptoms, and isolation if having the
Monitor trends in COVID-19 at national and global levels
disease or for contacts quarantine for 14 days.
Monitor mortality caused by, and indirectly associated
with, COVID-19 While UK and USA have emerged as the first two
Estimate morbidity countries in the world to launch the COVID vaccine, India
and mortality for health care workers has also launched one of the world's largest COVID
Assess the impact of control measures. vaccination drive. This is the first time that a vaccine for
Weekly aggregated reporting COVID-19 has been developed and launched in the country.
Dry run for the vacine: The dry run is a mock drill to test
The aim of ongoing weekly aggregate reporting is to
00tain further information on global COVID-19 trends for the laid out mechanisms for COVID-19 vaccination roll out
in the health system and to assess the operational feasibility
Cnnanced analysis. The variables are as follows (16):
of using CO-WIN application in field environment for
Number of confirmed cases planning, implementation and reporting at the block, district
Number of probable cases and state levels (17, 18).
TABLE 3
Surveillance systems across difterent sites/contexts
System Immediate Contact Virologic Cluster Mortality Serologic
Site tracing surveillance investigations
Context case notification surveillance surveillance
Community
Prima
Care Sites
non-sentinel ILI/ARI)
Hospitals
non-sentinel IL/SARI)
Sentinel
SARIsiteslLIARI
Closed settings
Health care-associated
SARS-CoV-2
infection
Travellers
at
ofentry points
Including
Source
butmnited
notli to long-term living facilities, prisons and dormitories.
(16)
 202 EPIDEMIOLOGY OF COMMUNICABL.E DISEASES

TABLE 4
Definition of the categories for transmission pallern
Category name Definition
No (active) cases No new cases detected for at least 28 days (two times the maximum incubation period),
in the presence of a robust survellance system. This imples a near-zero risk of infection
for the general population.
Imported / Sporadic cases Cases detected in the past 14 days are all imported, sporadic (e.g. laboratory acquired or
zoonotic) or are all linked to imported/sporadic cases, and there are no clear signals of further
locally acquired transmission. This implies minimal risk of infection for the general population
ation.
Clusters of cases Cases detected in the past 14 days are predominantly limited to well-defined clusters that 2 not
directly linked to imported cases, but which are all linked by time, geographic location and
common exposures. It is assumed that there are a number ot unidentified cases in the area.
This implies a low risk of infection to others in the wider community if exposure to these
clusters is avoided.
Community transmission - level 1 Low incidence of locally acquired widely dispersed cases detected in the past 14 days not linked
(CT1) to specific clusters; transmision may be focussed in cetain population sub-groups. Lowriskof
infection for the general population.
Community transmission -
level 2 Moderate incidence of locally acquired widely dispersed cases detected in the past 14 days:
(CT2) transmission less focussed in certain population sub-groups. Moderate risk of infection for the
general population..
Community transmission -level 3 High incidence of locally acquired widely dispersed cases in the past 14 days; transmission
(CT3) not
focussed in certain population sub-groups. High risk of iniection for the general population.
Community transmission -
level 4 Very high incidence of locally acquired widely dispersed cases in the past 14 days. Very high risk
(CT4) of infection for the general population.
Source: (16)

Vaccination for COVID-19 is voluntary. However, it is
advisable to receive the complete schedule of COVID-19
vaccine for protecting one-self against this disease and also to
limit the spread of this disease to the close contacts. It is
advisable to receive complete schedule COVID vaccine
irrespective of past history of infection with COVID-19. This
will help in developing a strong immune response against the
disease. Person with confirmed or suspected COVID-19
infection may increase the risk of spreading the same to others
at vaccination site. For this reason, infected individuals should
defer vaccination for 14 days after symptoms resolution.
Based on the potential availability of vaccines the
Government of lndia has selected the priority groups who
are vaccinated on priority as they are at higher risk. The first
group includes healthcare workers because they are at high
risk of contracting the infection and protecting them helps to
sustain essential health services. The vaccination of frontline
workers (police, home-guard, municipal worker, armed
forces etc.) will help in reducing the societal and economic
impact by reducing COVID-19 mortalities. The next group to
receive COVID-19 vaccine will be persons over 50 years of
age and persons under 50 years with comorbid conditions
because there is high mortality in this category. The reason
for inciuding more than 50 years of age group for vaccination
is that it will be able to cover 78% of persons having co-
morbidities and thereby reduce mortality on account of
COVID-19. More than 50 years of age group is divided into
two sub-groups. One sub-group is 60 years and above, they
will be vaccinated first. Second sub-group is between 50 to
60 years age group, they will be vaccinated after the first sub
group is cOvered. In subsequent phases the vaccine will be
given to the remaining persons. Only 100 persons will be
vaccinated at each designated vaccination site per day.
It can go in
The vaccination may not be sequential.
parallel for all beneficiaries depending on the availability of
ID a must for both registralion and
the vaccine. Photo is
verification of beneficiary at session site to ensure that the
intended person is vaccinated,
Any of the following mentioned ID with Photo may be
produced at the time of registration: Aadhar Card. Driving
License, Health Insurance Smart Card issued under the scheme
of Ministry of Labour, MGNREGA Job Card, official identity
cards issued to MPs/MLAs/MLCs, PAN Card, passbooks issued
by bank/post Office, passport. pension document, service
identity card with photograph issued to employees by Central'
State Govt./PSUs/Public Limited Companies, Voter ID and
Smart card issued by RGI under NPR.
Following online registration, beneficiary wil receive
SMS on their registered mobile number for the due date,
place, and time of vaccination. On getting due dose ot
COVID-19 vaccine, the beneficiary will receive SMS on their
registered mobile number. After all doses of vaccine are
administered, a QR code based certificate will also be sent to
the registered mobile number of the beneficiary.
It must be ensured
that the entire schedule of vaccination
is completed by only
one type of vaccine, as ditteren
COVID-19 vaccines are not interchangeable.
Vaccine
The vaccines approved for public use are: RNA
Ozinameran from Pfizer-Bio N Tech, and mRNA-l2i5 ro
(BBIBP-LO
Oena; conventional inactivatecd vaccines
rom Sinopharma and Coronavac from Sinovac) and virat
ector vaccines (Gam-COVID.Vac from Gamaleya Kesearc
nstilute and AZD1222 from University of Oxford and Astra
Zeneca).
adng corona vaccine contenders in India have
Deen granted approval for restricted use. Oxford Astra Leneca
oronavirus vaccine "Covishield", manufactured by seru
Institule of India, Pune and Bharat Biotech's COVID vaccin
"Covaxin" (approved for emergency use authorization).
rersons who are temporarily not eligible to get the
vaccine are (19) :
a Persons showlng symptoms of SARS-CoV
active
infection;
 CoVID 19 203
HIV and patients on
thl COVID-19 patients who have been given anti-SARS-CoV-2 5. Persons with immunodeficiency or condition cannot be
monoclonal antibodies Or convalescent plasma; immunosupprescents due to any
The vaccine should be given with caution to persons administered the Covaxin
ic)
Biotech's Covaxin will be
with a history of any bleeding or coagulation disorder People who are receiving Bharat
clotting factor deficiency Or which assures the recipients
platelet disorder, required to sign a consent form if any adverse event is ftound
coagulopathy; and medical care and compensation
the vaccine got restricted
linked to the vaccine. It is because General of India "in
td) Actually unwell and hospitalized patients (with or
Controller
without intensive care) due to any illness. approval by the Drugs
emergency situation in public interest as an abundant
Persons with a past history of COVID-19 infection can be to have more options,
precaution, in clinical trial mode,
administered the vaccine. Persons with a history of chronic especially in case of infection by
mutant strains The "clinical
and comorbidities (cardiac, clinical trials, that are essential
disease neurological, trial mode" is because phase-III The recipients will be
Dulmonary, and metabolic) are eligible for the vaccine to establish efficacy, are still ongoing."open label trial.
although efficiency of the vaccine may be less in these monitored more closely in a type of
patients. People taking the vaccine should avoid tobacco In case of Covishield, phase-II trial
were conducted in
and alcohol. The vaccines are not interchangeable. the combined efficacy
August 2020 in UK and Brazil, where
70 per cent effective. While
of the two trials was found to be
Covishield vaccine (19) still ongoing in India, the
bridge trials for Covishield are
to establish satety and
Covishield vaccine is a recombinant chimpanzee regulator looked at international data (19).
adenovirus vector vaccine, administered intramuscularly in efficacy. So no informal consent is sought
in two doses, 28 days apart. The But if you choose
deltoid muscle. iven In India vaccination is not mandatory.
protective level of antibodies are generally developed two which vaccine you will
to get vaccinated, you cannot choose
weeks after the 2nd dose of the vaccine. The vaccine has that is available at
get. You will be vaccinated by the vaccine day when India
been approved for individuals 18 years of age and above. the site. 16th January, 2021 is the
historical
To be stored at 2-8°C.
launched the vaccination drive.
Side effects Pfizer-BioNtech COVID-19 Vaccine (20)
efficacy.
The common side effects with Covishield vaccine are It is a messenger RNA vaccine with 95 per cent
for the vaccine
injection site pain and tenderness, headache, fatigue, myalgia, People 16 years and older are eligible
apart. It
discomfort, pyrexia, chills and nausea. Very rare events
of
administered in two doses intramuscularly, 3 weeks
vaccine It is not interchangeable.
demyelination disorder have been reported following is authorized for emergency use.
"without the causal relationship establishment". Storage is at -70°C.
Contraindications: (a) history of severe allergic reactioon
Contraindications (b) had a severe
after the previous dose of this vaccine:
1. Those below 18 years of age; reaction to any ingredient of this vaccine.
the
2. Pregnant and lactating mothers; Before taking the vaccine the provider must know
3. Those with allergic reaction to vaccine, plasma
centrical allergy, fever, bleeding
medical history of the person any
allergies; if the person is
products and notable food disorder if any, or taking blood thinner,
to cOVID-19 medicine that aftects immune
Anyone who has had adverse reaction immunocompromised or on a
system, pregnancy and breast-feeding, and have received
vaccine earlier; and
5. Persons with immunodeficiency or
HIV and patients on another COVID-19 vaccine.
condition cannot be
immunosupprescents due to any Side effects: Injection site pain, tiredness, headache
administered the Covid vaccine. muscle pain, chills, joint pain, tever, injection site swelling
and redness, nausea, teeling unwell, swollen lymph nodes.
Covaxin vaccine (19) There are remote chances of severe allergic reaction (within
in collaboration a few minutes to one hour after getting the dose).
The Bharat Biotech's vaccine, developed inactivated
with 1CMR and NIV Pune, is a whole virion
coronavirus vaccine. It is given intramuscularly in deltoid Moderna COVID-19 Vaccine (21)
days apart, to persons above It is a messenger RNA vaccine, with efticacy of about
muscle in two doses 28
at 2-8 C.
18 years of age. The vaccine should be stored 94.1 per cent, meant for people 18 years of age and above,
two doses given intramuscularly 1 month apart. It should be
Side effects stored between 25°C and -15°C temperature
Covaxin are injection
The common side effects following The vaccine provider must know about the history of
Site pain, fatigue, fever, headache,
bodyache, nausea, allergies, fever, bleeding disorders or history of taking blood
and cold and cough. thinner, pregnancy and breast-teeding in mothers, history of
abdominal pain, dizziness, sweating,
taking another COVID-19 vaccine and if the recipient is
Contraindications immunocompromised.
Those below 18 years of age;
1 Side effects: Side effects reported are (a) injection site
2.Pregnant and lactating mothers; reactions are pain, redness, swelling, tenderness; (b) general
to vaccine, plasma centrical side effects are tatigue, headache, muscle pain, joint pain,
5 Those with allergic reaction vomiting, and fever. Severe side effects are difficulty in
products and notable food allergies;
to COVID-19 breathing, swelling of tace and throat, fast heart beat, bad
Anyone who has had adverse reaction rash all over the body, dizziness and weakness.
vaccine earlier, and
 204 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

COVID-19 dead body management meninges, bones and joints, lymph glands, skin and
other
All staff
identified to handle dead bodies in the isolation tissues of the body. The disease 1s usually chronic with
area, mortuary, ambulance and those workers in the varying clinical manifestations. Ihe disease also
affects
crematorium/burial ground should be trained in the infection animals like cattle; this is known as "bovine tuberculosis"
prevention control practices. The health worker attending to which may sometimes be communicated to man. Pulmonart,
the dead body should perform hand hygiene, ensure proper tuberculosis, the most important form of tuberculosis which
use of PPE. Plug oral, nasal orifices of the affects man, will be considered here.
dead body to
prevent leakage of body fluids. Place the body in leak-proot
plastic body bag. The exterior of the body bag be Problem statement
decontaminated with 1 per cent hypochlorite.The body bag WORLD
can be wrapped with a mortuary sheet or sheet provided by
the family members. Embalming of the dead body should not Tuberculosis remains a worldwide public health
problem
despite the fact that the causative organism was discovered
be allowed. Autopsies should be avoided. The crematorium/
burial ground staff should be sensitized that COVID-19 more than 100 years ago and highly effective drugs
does
not pose additional risk to them. Viewing of the dead body by vaccine are available making tuberculosis a preventable and
unzipping the face, for the relatives to see the body for one last curable disease. Technologically advanced countries and
time is allowed. Bathing, kissing, hugging, etc. of have
achieved spectacular results in the control of tuberculosis.
the dead
body should not be allowed. Religious rituals This decline started long before the advent of BCG
such as reading
from religious scripts, sprinkling holy water and any
other last chemotherapy and has been attributed to changes in or
rites that does not require touching of
the body can be "non-specific" determinants of the disease such the
allowed. Large gathering at the crematorium/burial improvements in the standard of living and the quality life as
should be avoided. The funeral staff and family ground of the people coupled with the application of
members of available
should perform hand hygiene after cremation/burial technical knowledge and health resources.
(22).
It is estimated that about
References one-third of the current global
population is infected asymptomatically with tuberculosis,
1. NSBI Book Shelf (2020),
Features, evaluation and treatment of corona whom 5-10 per cent will develop clinical of
virus, last updated 4th Oct. 2020.
their lifetime (1). Most new cases and disease during
2. WHO (2021), WHO highlights deaths occur in
for SARS-CoV-2 variants, Jan. 2021. developing countries where infection is often
3. Govt. of India, Press release, 30th Dec. acquired
2020.
4 WHO (2020), Weekly update of global corona virus impact and childhood. The annual risk of tuberculosis infection in in
burden countries is estimated to be high
implications.
5. Govt. of India, Press release Patients with infectious pulmonary 0.5-2 per cent (2).
5A. COVID-19, Corona uirus pandemic, infect tuberculosis disease can
19th Feb., 2021. 10-15 persons in a year
6 WHO (2020), Transmission of SARS-CoV-2, implications of infection Globally, an estimated 10 million people had
prevention, precautions. tuberculosis
in the year 2019, a
7. Govt, of India(2020), Clinical
Management Protocol: COVID-19, number that has been declining very
version, 3rd July 2020. 5th slowly in recent years. There
8. WHO (2020), Clinical Management TB deaths among HIV-negative
were an estimated 1.2 million
of COVID-19, 27th May 2020.
9 Govt. of India (2020), National Centre for Disease reduction from 1.7 million in people and an additional (a
case definition and contact categories, Control, updated year 2000), and an additional
Director General of Health 208,000 deaths among HIV-positive
Services. people. Men aged
215 years accounted for
10. NIH, COVID-19 Treatment
guidelines, Testing for SARS-CoV-2 developed 56 per cent of the people who
infection, updated 7th Dec. 2020. TB in 2019; women accounted
11. ICMR (2020), ICMR revises and children (aged <15 for 32 per cent
12 WHO, Home care for patients
treatment protocolfor COVID-19
those
years) for 12 per cent. Among all
with suspected noval patients. affected, 8.2 per cent were
presentingwith mild symptoms corona infection people living with HIv (1
2021. and management of contacts,
20th Jan.
Globally, the burden of multidrug-or rifampicin-resistant
13. WHO (2020), Public TB (MDR/RR-TB)
as a
remains stable. In 2019, share of the number of TB cases
health guidelines for COVID-19
guidance, 16th Dec. 2020. Interim
14. Govt. of India (2020), Finalguidance TB cases and 18 an estimated 3.3 per cent of new
on management of COVID per cent of previously
15. Govt. of India (2020), Post cases. MDR/RR-TB. In treated cases had
2020.
COVID management protocol,13th
465,000 incident absolute numbers, there were
16. WHO (2020), Public Health
Sept. an estimat
cases of rifampicin-resistant
17. Govt. of India (2020),
Surveillance, 16th Dec. 2020 8 per cent had multidrug-resistant TB. India (27 per cen
TB
COVID-19 vaccine
strategy, help us help you. strategy communication China (14 per cent)
18. Govt. of India (2020), the largest burdens and Russian Federation (8 per cent) na
Frequently asked
vaccine, target group general questions on COVID-19
public. Geographically,
19. Govt. of India, Press release. were in South-East most people who developed TB in 2019
20. Pfizer-BioNtech COVID-19
and the Western Asia (44 per
Pacific (18 per cent), Africa (25 per C
Vaccine fact sheet
provider of the vaccine. for recipient and
of the cases is cent). cent
21. Moderna COVID-19 Vaccine
fact sheet for recipient the highest burden India with 26 pe
the vaccine and provider of perrate cent and China 8.4 per cent. country followe
22. Govt. of India (2020), incidence The
management, 15th March 20020
COVID-19 : Guidelines
more than at national level varies trom
on dead body
500 es 5 to
population per new and relapse cases per O0 O00
TUBERCULOSIS whole, most year. At the end of d as a
WHO regions 2019, tne
Tuberculosis is a Countries were
not on track and many nig ctones o
rden
M. tuberculosis. 1Thespecitic infectious disease the End TB Strategy. to reach the 2020
causes pulmonary disease primarily caused by mies
tuberculosis. It can affects lungs and Globally,
also affect intestine, 7.1 million
have been newly people
ple with TB were reporte
increase in TB diagnosed and notified Despite
notifications, in 201
there was still a larg gap
 TUBERCtH.OSiS 205
five indicators to
a0 million between the10number of people newly Development Goals (5). It focused on TB control. They
about
2.nd reported and the million people estimated neasure the implementation and impact of
incidence. prevalence
diagndaveloped TB. 1his gap is due 10 a combination of are case detection, treatment success,was DOTS. The WHO
rting of people diagnosed with TB and death, The core of the strategy Assembly in
underdiagnosis(if people
with TB cannot access health care TB strategy, adopted by the World Health TB epidemic
diagnosed when they do). Five countries nd a blueprint for countries to
end the
are not more than half of the global gap. They are ag 2014, isdown TB deaths, incidence and eliminating
accountec for Dy driving targets to reduce
per cent), Nigeria
(11 per cent), Indonesia (10 per catastrophic costs. It outlines global impact per cent
India (17
Pakistan (8 per cenl) and the Philippines (7 per cent). Bdeaths by 90 per cent and to cut new cases by 80family is
cent), that no
between 2015 and 2030 and to ensure the TB epidemic
hally in 2019, 69 per
cent of notified TB patients had
documented HIV test result. A total of 456,426 TB cases burdened with the costs due to TB. Ending newly adpted
of the
people living with HIv were reported (56 per cent of
y Z030 is among the health targets gone one step
incidence). Ot these, 88 per cent were on Sustainable Development Goals. WHO has cent reduction in
timatedtherapy (1).
the Turther and set a 2035 target of 95 per
incidence similar to
antiretroviral
deaths and a 90 per cent decline in TB today (6). For
The latest data for
2018 shows treatment success rate Current levels in low TB incidence countries
cent for TB, 57 per cent for MDR/RR-TB and further details, please refer to page 233.
of 85 per 1
5 patients living with HIV
In September 2018, the UN General
Assembly held its
76 per cent for
outcome was a
The preventive treatment for TB is expanding, especially first-ever high level meeting on TB. The
HIV and to SDOs and
in the
priority risk groups of people living with political declaration in which commitments ones added.
echildren under 5 years of age. However, most people eligible End TB Strategy were reaffirmed and new
for TB prevention,
preventive treatment are not accepting it (3).
Global targets for funding to be mobilized
for TB
TB is not known due to care and research, and for the number of people to be
The actual burden of paediatric were set for the first
diagnostic difficulties. It is assumed that about 10 per cent of treated for TB infection and disease,
total TB load is found in children. Globally, about 1 million time. The targets are as follows (1):
to occur every year, with 1. 40 million people treated for TB from 2018
to 2022,
cases of paediatric B are estimated
T

more than 100,000 deaths

(4). Childhood deaths from TB including
are usually caused by meningitis
or disseminated disease (2). -
3.5 million children
XDR-TB is documented among TB, including
Though MDR-TB and
overall 1.5 million people with drug-resistant
paediatric age groups, there are no estimates of 115,000 children.
burden because of diagnostic difficulties and exclusion of
TB preventive
children in most of the drug resistant surveys (4). 2. At least 30 million people provided with
treatment from 2018 to 2022, including
many developing countries, acquired drug resistance
In
6 million people living with HIV
high, because national tuberculosis control
-
remains million
programmes in these countries have not been able to 4 million children under 5 years of age and 20
people in other age groups, who are
household
achieve a high cure rate over a very long period of time,
even after the introduction of short-course chemotherapy.
contacts of people affected by TB.
Poverty, economic recession, malnutrition, overcrowding, 3. Funding of at least US$ 13 billion per year for universal
indoor air pollution, tobacco, alcohol abuse and diabetes access to TB prevention, diagnosis, treatment and care
make populations more vulnerable to tuberculosis. Increase by 2022.
in human migration has rapidly mixed infected with 4. Funding of at least US$ 2 billion per year for TB research
uninfected communities. To make global situation worse, from 2018 to 2022.
tuberculosis has formed a lethal combination with HIO.
The current COVID-19 pandemic threatens to reverse
The WHO has setInternational Standards for recent progress in reducing the global burden of TB disease.
uberculosis Care. These standards are intended to facilitate The global number of TB deaths could increase by around
the effective engagement of all care-providers in delivering 0.2-0.4 million in 2020 alone, if health services are disrupted.
hg-quality care for patients of all ages, including those
with smear-positive, smear-negative, extrapulmonary INDIA
tuberculosis, drug-resistant tuberculosis, and tuberculosis
combined with HIV infection. The basic principles of care TOr India is the highest TB burden country in the world in
people with, of having tuberculosis are the
terms of absolute number of incident cases that occur each
or suspec year. It accounts for 26 per cent of the estimated global
aeworldwide. The standards are intended to be incident TB cases in 2019. Table l shows the burden of
Xementary to local and national tuberculosis control tuberculosis in India, the estimated and reported cases for
Tesarethat are consistent with WHO recommendations.
hey not intended to replace local guidelines. There are the year 2019 (7, 8).
Sandards for diagnosis, 9 standards for treatment ana AGE DISTRIBUTION : Overall the age distribution of TB
andards for public health responsibilities. Please reter to
O publication: Weekly Epidemiological Record, No. , diagnosed incident cases shows a predominance
adolescent and young adult age groups between 15 to
in

aed 3rd Feb. 2006 for further details. 30 years of age, indicating ongoing disease transmission as
Or the past tuwo decades, national and international shown in Fig. 1. However, there is a wide variation in the
S in TB prevention, diagnosis and treatment have been age distribution pattern among the states. In southern states
guided of Kerala, Karnataka, Tamil Nadu, Andhra Pradesh and UTs
and
Subseau
equently the
DOTS strategy (mid-1990 until 2005) The of. Puducherry, Lakshadweep there is a general elderly
Strategy (2006-2015).
Nop TBstrategy Stop TB prevalence of TB towards the age S0+ year ranges. In other
was designed to chieve global TB targets states the incidence is similar to that of the country.
U5 within the context of the Millennium
206 EPIDEMIOLOGY OF COMMUNICABLE DISEASES
16,411 124,269
TABLE 1 0-4
Burden 21 ,660
tuberculosis in India (2019)
of 5-9 16,954 |
(Population: 1,366 million) 40,342 27,665
10-14
Number Rate (per 100,000 1,09,942 99,370
15-119
(thousands) population)
20-24 1.24,346 1,33.279
Estimates of TB burden, 2019 1.24,22
25-29 1,06,783 L
Incidence (Total) 2640 (1800-3630) 193 (132-266)
72,560 1,09,33
Incidence (HIV+TB) 5.2 (3.6-7.2)
71 (49-98) 30-34
Incidence (MDR/RR-TB) 9.1 (5,3-14)
124 (73-189) 35-39 62,120 L |1.12.487
Mortality (HIV negative TB) 436 (404-469) 32 (30-34) A8,821
40-44 1,08,820
Mortality (HIV positive TB only) 9.5 (6-14) 0.69 (0.44-1)
45-49 47,327 1,15,269
Estimated proportion of TB cases with MDR/RR-TB,"2019
50-54 42,474 1,09,065
New cases 2.8% (2.3-3.5)
Previously treated cases 14% (14-14) 55-59 31,924 ,481

Universal health coverage and social protection 60-64 41,628 1,11.743

TB treatment coverage 82% (60-120)| 65-69 25,11 70,931

(notified/estimated incidence), 2019 16.286 48,572
70-7
17% (12-24)|
TBcasefatality ratio
(estimated mortality/estimated incidence), 2019 75+ ,913 37,168

TB case notifications, 2019 150K 100K 50K OK

T
50K 100K 150K
Total cases notified 2,404,815
2,162,323 Female Male
Total new and relapse FIG. 1
%tested with rapid diagnostics at time of diagnosis 17%|
%with known HIV status 80% Age distribution of TB cases, India (2019)
- o pulmonary 78% Source:(7)
-% bacteriologically confirmed 57%
children aged 0-14 years 7%
THE ECONOMIC AND SOCIAL BURDEN OF DISEASE
%

owomen 34%
% men 59% Besides the disease burden, TB also causes an enormous
socio-economic burden to India. TB primarily affects people
TB/HIV care in new and relapse TB patients, 2019 in their most productive years of life. While two-thirds of the
Number (%)| cases are male, TB takes disproportionately larger toll
Patients with known HIV-status who are HIV-positive 46,741 2.7% among young females, with more than 50 per cent of female
- on antiretroviral therapy 44,517 95%| cases occurring before the age of 34 years (9).
|Drug-resistant TB care, 2019 Tuberculosis kills more women in reproductive age group
may
77% than all causes of maternal mortality combined, and it
%of bacteriologically confirmed TB cases tested for create more orphans than any other infectious disease.
ritampicin resistance New cases
tested for
%of bacteriologically confirmed TB cases cases 82% Nearly one-third of female infertility in India, is caused by
rifampicinresistance- Previously treated tuberculosis. The indirect impact of tuberculosis on children
| Laboratory-confirmed cases MDR/RR-TB: 66,255, XDR-TB":2,323 is considerable, as nearly 3 lacs children of tuberculosis
to
Patients started on treatment MDR/RR-TB° : 56,569, XDR-TB": 1,918 patients, either leave the school or take up employment
MDR/RR-TB cases tested for resistance to any fluoroquinolone 36,748 help support their families (6). A patient of tuberculosis
Treatment success rate and cohort size takes an average of three to four months to recuperate,
Success Cohort losing that much income. The loss is disastrous for those
to be
struggling against poverty. They are most likely
New and relapse cases registered in 2018 82% 1,908,683 vast majority (more than 90 per
74%
detaulters of treatment. The
Previously treated cases, excluding relapse, 140,834 burden of TB in India is caused by the
cent) of the economic
registered in 2018 loss of life rather than morbidity.
HIV-positive TB cases registered in 2018 74% 32,493
MDR/RR-TB cases started on second-line 49% 36,043| In India, tuberculosis is mainly a disease of the poor, The
treatment in 2017 majority of its victims are migrant labourers, slum dwellers,
XDR-TB cases started on second-line 36% 2,644 residents of backward areas and tribal pockets. Poor living9
treatment in 2017 conditions, malnutrition, shanty housing and overcrowading
TB preventive treatment, 2019 are the main reasons for the spread of the disease (10).
%
of HIV-positive people (newly enrolled in care) 45%| HIV increases a person's susceptibility to tuberculosis
on preventive treatment infection, and tuberculosis is one of the earles
of 33% (30-36)
% of children (aged<5) household contacts opporlunistic disease to develop amongst persons intected
bacteriologically-confirmed T5B cases on preventive treatment with HIV. It increases morbidity and mortality in
Estimates of TB and MDR-TB
consultation with countries.
burden are produced by WHO In
Ranges represent uncertainty intervals.
infected persons. HIV is the most potent risk factor
progression of TB infection to disease.
o
RR ls TB resistant to
MDR is TB resistant to rifampicin and isonlazid;
rifampicin. Since death rate is declining and the disease is showing
are
Calculated for pulmonary cases only,
TB treatment history.
cdecline in younger age groups, epidemiologists
Includes cases with unknown previous2019 and palients who were not beginning to think that perhaps we may have crossed
ne
Includes patients dlagnosed before
laboratory-confirmed, peak of the secular epidemic curve and are somewhere
Source: (7, 8) the beginning of the declining limb.
210 EPIDEMIOLOGY OF COMMUNICABLE DISEASES
mycobacteria have been isolated from man (19). These have
been classified into four groups (i) photochromogens
(e.g.
M. Kansasii); (ii) scotochromogens (e.g., M. scrofulaceum)
(ii) non-photochromogens (e.g., M. intercellulare)) and,
(V) rapid growers (e.g., M. fortuitum). All these are
mainly
saprophytic. Diseases attributed to them have resembled
pulmonary tuberculosis and chronic cervical lymphadenitis.
(b) SOURCE OF INFECTION There are two sources of
: with pulmonary tuberculosis. To transmit infection, the
intection -
human and bovine. (i) Human source: The most
Common source of infection is the human case whose sputum
is positive for tubercle bacilli and who has either received no
treatment or has not been treated fully. An estimated annual
average of 10-15 persons contract the infection from one
case ot intectious pulmonary TB. Such sources can discharge
The bacilli in their sputum for years. The tubercle bacilli in a
human case are usually a mixed group some multiply very
-
rapidly and some slowly. The more rapidly a bacillary strain
multiplies the more susceptible it is to the bactericidal action
of chemotherapeutic drugs. The slow multipliers are the
source of persister or dormant bacilli; they can remain alive
for years without causing harm to the host, but when
conditions are favourable they may start multiplying again
and cause active disease. That is, they are the seeds of a
future relapse (20). (ii) Bovine source: The bovine source ot
infection is usually infected milk. There is no detinite
evidence that bovine tuberculosis is a problem in this country
because of the practice of boiling milk before consumption.
(c) COMMUNICABILITY: Patients are infective as long
as they remain untreated. Etfective anti-microbial treatment
reduces intectivity by 90 per cent within 48 hours (21).
Host factors
(a) AGE : Tuberculosis affects all ages. Developing
countries show a sharp rise in infection rates from childhood
to adolescence. In India, from an average of 2 per cent in the
0-14 years age group", the intection rate climbs to about
20 per cent at age 15-24 years age group. In the developed
countries, the disease is now more common in the elderly.
(b) SEX :More prevalent in males than in temales.
(c) HEREDITY Tuberculosis is not a hereditary disease.
However, twin studies (22) indicate that inherited
susceptibility is an important risk factor. (d) NUTRITION:
Malnutrition is widely believed to predispose to tuberculosis.
As malnutrition is widely prevalent in developing world, it
will continue to affect the development of active disease,
out- come of treatment and spread of the disease.
(e) IMMUNITY: Man has no inherited immunity against
tuberculosis. It is acquired as a result of natural infection or
BCG vaccination. Past intection with atypical mycobacteria
is also credited with certain amount of naturally acquired
immunity. It is now known that both delayed hypersensitivity
and acquired resistance to tuberculosis are cell-mediated
responses. In most cases, the cellular immunity proves
adequate to limit further multiplication and spread of bacilli.
Social factors
Tuberculosis is a social disease with medical aspects. It
has also been described as a barometer of social welfare.
The social factors include many non-medical tactors such as
poor quality of Iife, pooT housing, and overcrowding,
population exploS1on, undernutrition, smoking, alcohol
abuse, lack of education, large families, early marriages,
lack of awareness of causes of illness, etc. All these factors
arë interrelated and contribute to the occurrence and spread
of tuberculosis. In fact, tuberculosis began to decline in the
western world long before the advent ot chemotherapeuti
drugs. This has been attributed to improvements inthe
quality of life.
Mode of transmission
Tuberculosis is transmitted mainly by droplet infection
and droplet nuclei generated by sputum-positive patients
particles must be fresh enough to carry a viable organism.
Coughing generates the largest number ot droplets of all
sizes. The frequency and vigour of cough and the ventilation
of the environment influence transmission of infection.
Tuberculosis is not transmitted by tomites, 5uch as dishes
and other articles used by the patients. Sterilization of these
articles is therefore of little or no value. Patients with
extrapulmonary tuberculosis or smear-negative tuberculosis
constitute a minimal hazard for transmission of infection
Incubation period
The time from receipt of infection to the development of
a positive tuberculin test ranges trom 3 to 6 weeks, and
thereafter, the development of disease depends upon the
closeness of contact, extent of the disease and sputum
positivity of the source case (dose of infection) and host-
parasite relationship. Thus the incubation period may be
weeks, months or years.
THE CONTROL OF TUBERCULOSIS
Tuberculosis control means reduction in the prevalence
and incidence of. disease in the community.
Since tuberculosis is an infectious disease, the basic
principles of prevention and control are the same as for any
other intectious disease. The control measures consist of a
curative component namely case tinding and treatment:
and a preventive component - namely BCG vaccination.
These are the two fundamental components of a nationa
tuberculosis programme. The most powerful weapon.
however, is the combination of case-finding and treatment.
Case-finding
a. THE CASE
The first step in a tuberculosis control programme is eary
detection of sputum-positive cases. This should be an
intensive, on-going programme
b. PASSIVE CASE FINDING
An overwhelming majority of patients of pulmonary
o
uoercuiosIs have one or more of the symptoms reterable
many or
chest, such as persistent cough and fever, and tue
(over 60 per cent) seek medical advice on their o
initiative. The chest symptoms often develop early,
oerore the disease has gone on to an advanced stage. Ini
e
the most fertile group for case-finding.
c. INTENSIFIED TB CASE FINDING (23)
Intensified cases finding activity (ICF) is basicaly
provider initiated activity with the primary objectveod Ted
detecting TB cases early by active case finding in tarwn
groups and to initiate treatment promptly. It canwithou
haut
people who anyway have sought health care witn o eek
o
symptoms or signs of TB and also people who do
care. Increased coverage can be achieved by focusnons lations
clinically, socially and occupationally vulnerable popd that
who have greater risk of TB. It must be remembete

6eroening' is a dynamic processand the prioritization of
.nerable groups, choice of screening approach and
roening interval should be regularly reassessed by the
aramme. Decisions on when and how to screen for TB,
Ph vulnerable groups to prioritize and which screening
tool to use will depend on the Vulnerable group, the capacity
of the health system, and the availability of resources.
Screening strategies
1. Community screening
can be done by
Inviting people to attend screening at a mobile facility or
a fixed facility. Invitations may target specifically people
within a given vulnerable group, those
who have had recent close contact with someone who
has TB and people with symptoms of TB.
Going door-to-door to screen households.
2 Institutional screening
In health care facilities: Systematically perform active
screening of vulnerable individuals attending hospitals
and other health care institution
In congregate settings: Systematically perform active
screening of vulnerable individuals in shelters, old age
homes, refugee camps, correctional facilities and
other specific locations such as workplaces.
Recommendations on at risk or vulnerable groups to
be screened
A vulnerable group is any group of people in which the
prevalence or incidence of TB is significantly higher than in
the general population. The recommended vulnerable
groups to be considered for intensified case finding are
discussed in detail on page 234.
d. CASE-FINDING TOOLS
Tools for microbiological confirmation of TB are (24)
Sputum Smear Microscopy (for AFB)
1 bacilli than one taken later in the day. It may be difficult for
Zeihl-Neelsen staining
Fluorescence staining
2 Culture:
Solid (Lowenstein Jensen) media
-Automated Liquid culture systems e.g. BACTEC MGIT
960, BacT Alert or Versatrek etc.
3. Drug Sensitivity Testing
for
-Modified proportionate sensitivity testing (PST)
MGIT 960 system
testing
Economic variant of proportion sensitivity
(1%) using LJ medium
4 Rapid molecular diagnostic tests:
Line probe assay (LPA) for MTB
complex and
LPA), and FQ
(FL
detection of RIF & INH resistance
and SLI resistance (SL LPA)
(NAAT) (CBNAAT
Nucleic acid amplification test
truenat)
Oupportive tools for the clinical diagnosis of TB
Chest X-ray and other radiological tests
gamma release
dberculin skin test (TST), Interferon and
assay (IGRA) and other blood tests, histopathology
other tissue-based tests.
commonly used
S
mot microscopy being the most the last
od tor microbiological diagnosis of TB for
TUBERCULOSIS 211
value in TB diagnosis
several decades, has had enormous in children and PLHIV.
but with limited sensitivity, more so of microscopy are
Under the programme, two methods microscopy using
Currently being used ZN stain-based
conventional microscope and light emitting.
(LED FM): Culture
Diode based fluorescent microscopy method for TB
though highly sensitive and
specific
results and hence does
diagnosis, requires 2-8 weeks to yield
culture is used for
not help in early diagnosis. However, treatment to detect
follow-up of patients on drug resistant TB for long term
early recurrence. In addition, it is also used free cure.
follow-up for DS TB patients, to ensure relapse
indicator
Liquid culture system Mycobacteria growthsystem that
(MGIT-B) an automated culture
tube system is
culture results
detects the growth of mycobacteria. The are available
are usually available upto 42 days. DST results
turn positive.
14-26 days after the cultures
Molecular assays Polymerase-chain-reaction (PCR)
used for
based technologies using various modifications are
detecting the presence of putative resistance genes (rpoB for
ritampicin, katG and inhA for Isoniazid etc.).
Sputum examination: Sputum smear examination by
direct microscopy is now considered the method of choice.
The reliability, cheapness and ease of direct microscopic
examination has made it number one case-tinding method
all over the world. It enables us to discover the
epidemiologically most important cases of pulmonary
tuberculosis, i.e., those excreting tubercle bacilli in their
sputum. This is the group which contributes most of the new
cases to the "pool of intection every year.
Collection of sputum samples
A pulmonary tuberculosis suspect should submit two
sputum samples for microscopy. The chances of finding
TB bacilli are greater with two samples than with one
sample. Secretions build up in the airways overnight. So an
early morning sputum sample is more likely to contain TB
an out-patient to provide two early morning sputum
amples.Therefore in practice an out-patient usually
provides sputum samples as follows:
Patient provides an "on-the-spot" sample
1 1
day sample
under supervision when presenting to the
health facility. Give the patient a sputum
container to take home for an early morning
sample the following morning
day 2 sample 2 Patient brings an early morning sample.
If the patient is coming from a long distance or there is
likelihood that the patient may default to give a second
sample, 2 spot specimens are collected with a gap of one
hour (25)
Ziehl-Neelsen acid-fast stain
This simple stain detects acid fast bacilli. The procedure is
as follows:
1. Fix the smear on the slide by passing the slide with the
smear up about three times slowly through a flame. It
can also be done by covering the smear with alcohol and
letting this evaporate.
2. Cover with carbol fuchsin, steam gently for 5 minutes
over direct flame (or for 20 minutes over a water bath).
Do not permit slide to boil or dry out.
 (faulty sansnpling
COMMUNICABIL1E DISEAS
smear microscopy), processing
12
EPIDEMIOLOGY OF
long before sm
or faulty mear preparation nd
sputum for smear sputum smears (inadeauat. e time
of interpreting attention to smear
Wash with deionized water. cent staining), or inadequate
acid-alcohol (95 per smear or
Decolourize in 3.0 per cent until only a spent examining because of administrative errors
ethanol and 3.0 per
cent hydrochloric acid) examination), or incorrect labelling of sample
(misidentification of patient,
faint pink colour remains. documentation).
Wash with water.
mistakes in
Loeffler's methylene blue.
Counter stain for 1 minute with Fluorescence nicroscopy industralized
let it dry. is mainiy used in
Wash with deionized water and Fluorescence microscopy auramine stain. The advantar.
with
countries. It is performed the speed of examination. The d
Slide reporting (26) is from
disease of FA microscopy bigger. Scanning of one
length of mear
in a smear rellects times
The number of bacilli seen Therefore, is important foo
of view is 5-10
it 1--2 minutes
everity and patient infectivity. will require only
on each smear. The table
ecord the number of bacilli seen of reporting using 1000 X fluorescence microscopy (LEDs)
elow shows the standard
method Light-emltting diode
magnification. LEDs provide a much
less expensive light source for
a recent WHO evaluation, the
Result reported fluorescence microscopy. In
Number of bacilli microscopy was found to be
diagnostic accuracy of LED fluorescence microscopy
per 100 oil immersion fields
0 comparable to that of conventional
No AFB
conventional Ziehl-Neelsen
1-9 AFB per 100 oil immersion fields
Scanty (or number and superior to that of recommended that LED
AFB seen) microscopy. It is theretore to conventional
10-99 AFB per 100 oilimmersion fieldsint (1+) microscopy be phased in as an alternative and low-volume
(2+) Z-N light microscopy in both high
1-10 AFB per oil immersion field
per immersion field +++ (3+) laboratories (27).
>10 AFB oil

Laboratory technicians should examine both the

sputum
must record the result
samples from each TB suspect. They
of each sputum sample with the laboratory reference
request
number in the laboratory register and on the sputum
form. Results as indicated above are made available to the
clinician who can then categorize the patient.
It is advised
Rapid diagnostic tools include
The CB-NAAT system detects DNA sequences,
specific
rifampicin
for Mycobacterium tuberculosis complex and
resistance by polymerase chain reaction.
It concentrates
mycobacterium tuberculosis bacilli from sputum samples,
isolates genomic material from the captured bacteria
by

that the smear examined by one microscopist should not genomic DNA by
sonication and subsequently amplifies the
exceed 20 per day as visual fatigue leads to a deterioration PCR. The process identifies clinically relevant, rifampicin
of reading quality (27). One positive specimen out of the resistance inducing mutations in the RNA polymerase beta
two is enough to declare a patient as smear positive TB. (rpoB) gene in the Mycobacterium tuberculosis genome in a
Sputum smear microscopy for tubercle bacilli is positive real time format using fluorescent probes called molecular
when there are at least 10,000 organisms present per ml of beacons. Results are obtained from unprocessed sputum
sputum. The sputum smear positivity rate in TB/HIV patient samples in 90 minutes.
depends on the degree of immunocompromise. If the degree
of immunocompromise is mild, the likelihood of positive Line Probe Assay (LPA) :
sputum smear is similar to HIV negative patient. If Line Probe Assays detect DNA sequences specitic tor
immunocompromise is severe, the likelihood of positive
Mycobacterium tuberculosis complex as well as mutations
sputum smear is decreased because of decreased
conterring resistance. Sputum samples are decontaminated
inflammation in lungs (26).
and the concentrated deposit subjected o smear
False-positive results of sputum smear microscopy. DNA is extracted from all smear positive
microscopy samples and subjected to PCR:; while all smear negative
A false-positive result means that the sputum smear result
samples are inoculated in liquid culture and LPA performed
is positive even though the patient does not really have
using the culture isolate obtained upon growtn o
Mycobacteria. The PCR amplified products are revers
sputum smear-positive PTB. This may arise because of the
following: red stain retained by scratches on the slide;
hybridized on nitrocellulose strips containing probes specin
for detection of M.TB and
accidental transfer of AFBs from a positive slide to a mutations associated with drug
negative one; contamination of the slide or smear by resistance. First line LPA detects resistance to Rifampicin
(rpoB) and Isoniazid (katG, inhA),
environmental mycobacteria; presence of various particles while second line L
that are acid-fast (e.g. food particles, precipitates, other detects iluoroquinolone class (gyrA, gyrB) an
second line injectable class resistance
microorganisms). resistance (rrs, eis).
Nucleic Acid Amplification Test (NAAT)
False-negative results of sputum smear provides accura
and rapid diagnosis of TB by detecting Mycobacteriu
microscopy tuberculosis (M. tuberculosis)
A false-negative result conferring mutations, in sputum and Rifampicin (Rif) resistan
means that the sputum smear
result is negatíve even though the patient really specimen specimen as wel as
from extra-pulmonary Under the
sputum smear-positive PTB. This may arise does have programme, its use is sites.
recommended for diagnosis ot LD TE
because of
problems in collecting (patient provides
inadequate sample, in presumptive DR-TB patients
population such as children, and TB preferentially in TB
inappropriate spufum contajner used or sputum PLHIV, Extra-pulmonary
stored too and in smear negative
TB as per the diagnostic algoritn

Radiography
Chest X-rays are iselul lor the diagnosis of smea
negative plulmonaty 5 and T13 in children. It is not
tinely indicated in simear-postive cases. X-tays are
inuable tools for the diagnosis of pleural and pericardial
effusion, especially in early stages of the disease when
clinical signs are minimal. ft is essential in the diagnosis of
niliary TB. The other indications are frequent or severe
haemoptysis to exclude bronchiectasis or aspergilloma and
in patients needing speciflic treatment for pneumothorax.
TUBERCULIN TEST
The tuberculin test was discovered by Von Pirquet in
1907. A positive reaction to the test is generally accepted as
evidence of past or present infection by M. tuberculosis. The
tuberculin test is the only means of estimating the
prevalence of infection in a population
Tuberculin : Only two tuberculins have been accepted
as standard tuberculin by WH0, i.e., purified protein
derivative-S (PPD-S) and PPD-RT 23. PPD is standardized
in terms of its biological reactivity as tuberculin units (TU).
A standard 5 tuberculin unit (5 TU) dose of PPD-S is defined
as delayed skin activity contained in a 0.1 ug/0.1 ml dose of
PPD-S. 1 TU of PPD-RT 23 is equivalent to 5 TU of
PPD-S. In India PPD-RT 23 with Tween 80 is used. Tween
80 is a detergent added to tuberculin to prevent their
adsorption on glass or plastic surface. Use of tuberculin
strength of1 TU is recommended for standard Mantouxtest
in India.
MANTOUX TEST: The Mantoux test is carried out
injecting 1TU of PPD in 0.1 ml intradermally on the flexor
surface of the left forearm, mid-way between elbow and
wrist. The injection should be made with a tuberculin
syringe, with the needle bevel facing upward. When placed
correctly, injection should produce a pale wheal of the skin,
6to10 mm in diameter. The result of the test is read after
48-96 hours but 72 hours (3rd da
is t he al.
Tuberculin reaction consists of erythema and induration.
Since erythema is sometimes difficult to measure, induration
alone is measured (horizontal transverse diameter of
induration in millimetres, using a transparent plastic ruler or
callipers. Reactions exceeding 10 mm are considered
Ositive. Those less than 6 mm are considered "negative".
hose between 6 and 9 mm are considered "doubtful", i.e.,
ne reaction may be due to M. tuberculosis or atypical
ncobacteria. If there is no induration, the result should be
recorded as 0'.
t has been further observed that strong reactors (i.e.,
uose showing 20 mm or more induration) have greater
ances of developing tuberculosis than those showing
ominduration. Those with less than 5 mm induration
ae mmore risk of developing tuberculosis than those with
induration. Studies indicate that 92 per cent of
cases occur in persons who are already tuberculin
eactors (28). These findings illustrate the prognostic
significance of
the test
assification
Teaction (29) of positive tuberculin skin test
:
A tul
transu uin skin test reaction is considered positive if the
e diameter of the indurated area reaches the size
COne
Considera or the specific group. All other reactions are
negative. The classificaiton is as follows:
1EREKISIG 213
CGroup
Induration
Si2e
5 mm 1. HIV-posítive persons
2. Recent contacts of individuais with active
tuberculosis.
films
3. Persons with fibrotic changes on chest
5uggestive of prior tuberculosis.
4. Patients with organ transplants and ather
immunosuppressed patients (rereivingthe
equivalent of > 15 mgd of prednisone for manth or
I
more)
2 10 mmm 1. Recent immigrants ( <5 years) from countries with a
high prevalence of tuberculosis (eg. Asia, Africa.
Latin America.
2. HIV-negative injection drug users.
3. Mycobacteriology laboratory personnel.
4. Residents of and employees in the foliowing high-
risk congregate settings: correctional institutions
nursing homes and other long-term facilities for the
elderly: hospitals and other health care facilities
residential facilities for AIDS patients; and homeless
shelters.
5. Persons with the following medical conditions that
increase the risk of tuberculosis: gastrectomy. 2 10%
below ideal body weight. jejunoileal bypass, diabetes
mellitus, silicosis. advanced chronic kidney disease.
some hematologic disorders. íeg. leukemias
lymphomas) and other specitic malignancies eg.
carcinoma of the head or neck and lung.
6. Children <4 years of age or infarnts, children and
adolescents exposed to adults at high risk.
215 mm 1. Persons with no risk factors for tuberculosis.
A
negative tuberculin test must also be interpreted with
caution. For many years, it has been assumed that a
negative test constituted strong evidence against the
presence of active tuberculous disease in the majority of
cases. It has been shown that in the majority of patients with
tuberculosis, the cellular immune response may be
depressed. It means a negative tuberculin test cannot be
relied upon to exclude tuberculosis. The dermal
hypersensitivity to tuberculin can aiso be lost in various
states of immune suppression, e.g.. malignancy, Hodgkin's
disease, HIV infection, malnutrition, severe bacterial
infection (including TB itseli), viral infections (e.g. measles,
chickenpox, glandular fever), recent tive-virus vaccination
(e.g. measles), immunosuppresive drugs (e.g. steroids) and
incorrect injection of PPD. Therefore, too great a diagnostic
significance should not be placed on a negative tuberculin
test (18).
Two-step testing
Some people who were previously infected with TB
may
have a negative reaction when tested years after infection,
as
the immune system response may gradually wane. This
initial
skin test, though negative, may stimulate (boost)
ability to react to tuberculin in tuture tests. Thus,
the body's
a
reaction to a subsequent test may be misinterpreted positive
infection, when in fact it is the result of the boosted as a new
to an old infection. Giving a second TST atter reaction
negative TST reaction is called a two-step testing. Use an initial
step testing is recommended tor initial skin of two-
testing of adults
who will be retested periodically (e.g, health
care workers).
The first test is read 48-72 hours after
If the first test is positive,
injection.
-
consider the person infected.
lf the first test is negative, give a
three weeks after the first injection.
second test one to
2 EPIDEMIoLOGY OF COMMUNICABLE DISEASES
The second test is read 48-72 hours after injection.
-It the second test is positive, consider the person
previously infected.
I1
the second test is negative, consider person
-
the
uninfected.
,The validity of tuberculin test, like all medical tests, is
subject to variability. It is limited by lack of specificity. Apart
rom errors associated with the mode of administration,
reading of results and the test material used, there are other
actors such as cross-reactions due to sensitization by other
mycobacteria, which should be taken into account. In
countries with a high coverage of BCG, which also produces
Tuberculin hypersensitivity, tuberculin test has lost its
sensitivity as an indicator of the "true" prevalence of
intection The true prevalence rates of infection may be
exaggerated by infection with atypical mycobacteria as well
as the boosting effect" of a second dose of tuberculin
producinga larger reaction than the first (30).
It is often assumed that delayed hypersensitivity as
measured by tuberculin testing is a correlate of the
protective immune response. But evidence indicates that
this hypersensitivity is irrelevant to the ability of the host to
combat the disease. Despite these limitations, the tuberculin
test continues to be the only tool tor measuring the
prevalence of tuberculous infection in a community. It has
been aptly said that tuberculin test "must be approached
with respect, administered with care, read with deliberation
and interpreted with sentient discrimination.
TB Interferon gamma release assays (1GRAs)
The Interferon Gamma Release Assays (IGRAs) are a new
type of more accurate test for TB. 1GRAs are blood tests that
measure a person's immune response to the bacteria that
cause TB. The immune system produces some special
molecules called cytokines. These TB tests work by detecting
a cytokine called the interteron gamma cytokine. In practice
you carry out one of these TB tests by taking a blood sample
and mixing it with special substances to identify if the
cytokine is present. Two IGRAs that have been approved and
are commercially available, are the QuantiFERON® TB Gold
test, and the T-SPOT® TB test. The advantages of an IGRA
TB test includes the fact that it only requires a single patient
visit to carry out the TB test. Results can be available within
24 hours, and prior BCG vaccination does not cause a false
positive result. Disadvantages include the fact that the blood
sample must be processed fairly quickly, laboratory facilities
are required, and the test is only for latent TB. It is also
thought that the IGRAs may not be as accurate in people who
have HIV. In low prevalence resource rich settings, IGRAs are
beginning to be used in place of the TB skin test (31).
Case-finding should not be an end in itself. It is of little
value as a control measure unless followed by chemotherapy.
Resources and efforts should be directed towards primary
health care, rather than irrational case finding
Please refer to page 217 for the flow chart for diagnosis
of tuberculosis in adults, as followed by NTEP.
Chemotherapy
The development of effective treatment for tuberculosis
has been one of the most significant advances during this
century. With the evolution of controlled trials (see page 92),
the chemotherapy of tuberculosis is now more rationally
based, than in the treatment of other infectious diseases.
Chemotherapyis indicated in every case of active
tuberculosis. The objective of treatment is cure that is, the
elimination of both the fast and slowly iplying
(including the persisters) from the patient's body. Th Dacil
of chemotherapy are judged not by the anatomic etfects
lesions, but mainly by the elimination of bacili rngof
m
patient's sputum. Chemotherapy should be easilu the
free of charge to every patient detected. It should
n bDe
adequate, appropriate and applied to the entire Te pool
infectors in the community.
must
atientthecompliance is criticallyof
important; the patient take correct
correct dosage tor the correct length of time. Ineo the
treatment puts the patient at risk of relapse and
development of bacterial resistance and, importanth he
community at risk of infection with resistant organisms ne
Anti-tuberculosis drugs
There are now twelve or thirteen
drugs active against
M. tuberculosis, of which, six are considered to be essential
An antitubercular drug should satisfy the following riteria:
(a) highly effective (6) free from side-effects (c) easu
to
administer, and (d) reasonably cheap. The currently Used
drugs may be classified into two groups : bactericidal
and
bacteriostatic. The bactericidal drugs kill the bacilli in ivo.
The bacteriostatic drugs inhibit the multiplication of the bacilk
and lead to their destruction by the immune mechanism of the
host. A brief review of these drugs is given below.
THE FIRST-LINE DRUGS
BACTERICIDAL DRUG3s
Rifampicin (RMP)
RMP is a powerful bactericidal drug. It is a better
sterilizing agent than INH. It permeates all tissue membranes
including the blood-brain and placental barriers. It is equally
effective against intracellular as well as extracellular bacili. It
is the only bactericidal drug active against the "persisters"or
dormant bacilli which are found in the solid caseous lesions,
all other drugs being inactive (32). In this regard, it has a
distinct advantage over INH. Rifampicin is of special value
when the bacilli resists other drugs. In combination with INH,
it can cure even extensive tuberculosis, in about 9 months.
RMP is used only as oral drug. It is so well absorbed that
there is little need for parenteral administration. The dose
should be taken at least one hour before or 2 hours ater
food because absorption is reduced by food. It is never uised
alone for the treatment of tuberculosis, but always used n
combination with INH or another drug.
Many patients develop nausea at the start of treatmen
but this passes off. The toxic effects include hepatotoxicu
gastritis, influenza-like illness, purpura, thrombocgtope
aruy
and nephrotoxicity. The patient should be told that the
will turn the urine red; this can be used as test of complan
PAS delays its absorption; hence concii
administration with PAS should be avoided. If RMF,
stopped tor some reason, it should not be restarted wi
3 weeks to avoid hypersensitivity.
INH
INH ranks among the most powerful drugsell
treatment of tuberculosis. It can easily penetrate and
membrane, and is thus active against inrd ADidly
extracellular bacilli. Its action is most marked onlies
multiplying bacilli. It is less active against slow TmE1S
INH gets widely distributed in the body incluains cos
ease of administration, freedom from toxicity anu
makes it an ideal component for any drug regime
 COMMUNICABIE DISEASESs streptomun
EPIDEMIOLOGY OF by either
216 pyrazinamide, supplemented months, drOrin
followed by 2 drugs
ethambutol) for a period
2
However, a few patients do
oft
side-effects. phase, (INH plus rifampicin
significant drug to monitor or
develop major reactions and it is important one of the the continuation daily or intermittently. The treatOr tment
who develops thioacetazone) given and monitored mainl by
clinically all the patients. patient
A
again (32)1 supervised
never receive that drug must be fully
tolowing reactions must bacteriological examination.
Drug
Reaction responsible TREATMENT, SHORT
DIRECTLY OBSERVEDCHEMOTHERAPY
Thioacetazone (DOTS)
COURSE
a. Severe rash. agranulocytosis Streptomycin
balance cure by providing the most
b. Hearing loss or disturbed Ethambutol DOTS is a strategy to ensure the
CVisual disturbance (poor vision and
effective medicine and
confirming that it is taken. It is
perception) documented to be effective
colour
thrombocytopenia Rifampicin only strategy which has been In DOl5, during the
d. Renal failure, shock or Pyrazinamide worldwide on a programme basis, or other trained
a health worker
e. Hepatitis intensive phase of treatment swallows the drug in his
person watches as the patient
Fwo-phase chemotherapy presence. During continuation phase, the patient is issued
the effective combipack,
It is well recognized that there are two phases in or medicine for one week in a multiblister of which
a short, aggressive the presence
treatment of tuberculosis: (i) the first
is of
the first dose is swallowed by the patient
in
course of treatment, lasting
health worker or trained person.
intense phase, early in the he consumption of
intensive phase, three or more drugs also checked by return
1-3 months. During this bacilli as possible. The more medicine in the continuation phase iS
are combined to kill off as many initially, the less likely are the patient comes to
of empty multiblister combipack, when
rapidly the bacilli are killed is also lessened. collect medicine for the next week. The drugs are provided
"persisters to emerge. The risk of relapse is aimed at sterilizing the in patient-wise boxes with sufficient shelf-life.
(ii) the second or "continuation phase
bacilli. In the standard
smaller number of dormant or persisting not less INTRODUCTION OF DAILY DOSE
anti-tuberculous therapy, the duration of treatment was REGIMEN IN NTEP
complete sterilization of the bacilli.
than 18 months to achieve this
With the introduction of rifampicin and pyrazinamide,
The technical and operational guidelines-2016 for
TB
period is now successfully reduced to 6-9 months.
control in India, define major groups of TB patients who
are

offered standard treatment regimen. Patient's classification is

DOMICILIARY TREATMENT
The self-administration of drugs (generally oral drugs) by
the patients themselves without recourse to hospitalization
is
called domiciliary or ambulatory treatment. The classical
controlled clinical trials (35) carried out at the Tuberculosis
Chemotherapy Centre, Chennai showed that the incidence of
tuberculosis was no greater in the contacts of patients treated
at home than in the contacts of patients treated in sanatoria.
It is now universally accepted that with good chemotherapy,
hospital treatment has no advantage over domiciliary
treatment, and domiciliary treatment is to be preferred
because in the long run, it is so much cheaper than hospital
treatment, and that it can be managed by the primary health
care system and the general health services of the country. It
may be mentioned that it was this study, the classical Chennai
Study, that prompted a radical departure from the traditional
sanatorium to ambulatory or domiciliary treatment.
SHORT-cOURSE CHEMOTHERAPY
For a long time, the standard duration of tuberculosis
chemotherapy was 18 months. In 1972, Wallace Fox and his
colleagues from the British Medical Research Council
showed that the addition of ritampicin or of pyrazinamide to
regimens containing INH made it possible to reduce the
duration of treatment
There are a number of advantages of short-course
chemotherapy, viz. rapid bacteriological conversion, lower
failure rates and a reduction in the frequency of emergence
of drug-resistant bacilli. Patient compliance is improved,
they become non-infectious earlier. The disadvantage is that
the high cost of short-term chemotherapy militates against
its wider use in developing countries.
There are now a number of short-course
6 months duration that are highly effective, regimens of
of low toxicity,
and well-tolerated. These potent regimens are based on
an
initial intensive phase with 4 drugs (INH, rifampicin
and
TB:
based on drug susceptibility result as drug-sensitive TB. For
and
mono, poly, RR, multi and extensively drug resistant
TB
drug-sensitive TB patients, the thrice weekly intermittent
regimen used since inception of the programme has been
switched to a daily fixed dose combination regimen (34)
1. MANAGEMENT OF DRUG SENSITIVE
TUBERCULOSIS (2019)
Early identification of people with a high probability of
having active TB (presumptive TB) is the most important
activity of the case finding strategy. Screening and diagnosing
patients with appropriate tests and strategies will largely
determine the response to appropriate treatment. Passive case
finding alone can lead to missed cases or delayed diagnosis.
All presumptive TB will undergo sputum smear
examination (ZN/LEDFM). Two specimens are collected
(spot-early morning or spot-spot). If the first smear is positive
and the patient is not at the risk of drug resistant TB, he wi
be categorized as microscopically confirmed TB (sensitivi
Status not known). If the first smear is negative, CXR may
considered and if reported as suggestive of TB, the 2n
sample will be subjected to smear and CBNAR
simultaneously. Based on CBNAAT results, patient will be
categorized asmicrobiologically confirmed drug sensitive
For NTEP endorsed TB diagnostics, Fig. 2 shows the
diagnostic algorithm for pulmonary tuberculosis.
Pre-treatment counselling and evaluation
The patient and his/her family members shoula be
cOunselled about the type of disease, mode of spreau the
treatment duration and dosage schedule, common side
effects and methods to prevent arular
treatment and consequences of them, importance Oaing
of co-morbidities like diabetes,irregular
treatment, screan
líver or renal disease fo
neurological disorder etc. It is
also important to look for
 TUBERCULOSIS 217
Presumptive TB patient

Smear examination CXR

Smear positive Smear positive, & Clinical

Smear negative Smear negative or not available suspicion
and CXR but CXR not but CXR CXR not suggestive of TB obr
suggestive of TB suggestive of TB Suggestive of TB not available high

CBNAAT

PMDT criteria, high

MDR settings

MTB detected MTB not detected or CBNAAT Consider Clinically

result not available alternate diagnosed TB
diagnosis
and refer
to specialist
Refer to Alternate
Rif sensitive Rif indeterminate Rif resistant diagnosis
management of
Rif resistance

Repeat CBNAAT
Microbiologically on 2nd sample
confirmed TB
*All presumptive TB cases should be offered HIV
Indeterminate on 2nd sample, collect counselling and testing, however diagnostic work
up for TB must not be delayed.
fresh sample for Liquid Culture/LPA
FIG. 2
Diagnostic algorithm for pulmonary TB
rce: (23)

stance abuse especially tobacco (in any form) and alcohol. and activities relating to the detection, assessment.
io-economic status of the patient may be assessed to link understanding and prevention of adverse effects or any other
v/her with appropriate treatment support schemes. HIV drug-related problem". It is fundamental activity to inform
ing should be done in all the cases of TB. This is important the management of patient safety measurement in health
ensure that all HIV positive cases of TB receive anti- care. It is a public health surveillance activity. Priority is given
roviral therapy and co-trimoxazole preventive therapy (23). to establish pharmacovigilance at drug resistance TB centres.
Since the drugs used in the treatment of tuberculosis are
Own to produce adverse effects, a proper pre-treatment
Recommended daily dose regimen for drug
aluation is essential to identify patients who are at sensitive TB (2019)
creased risk of developing such adverse effects. The pre -
The principle of treatment for tuberculosis (other than
2atment evaluation includes the following : confirmed drug resistant forms of TB) with daily regimen is
Detailed history (including mental illness, seizure, drug to administer daily tixed dose combinations of first-line
anti-tuberculosis drugs in appropriate weight bands.
and alcohol abuse etc).
Weight and height. Fixed dose combinations (FDCs)
Complete blood count.
Fixed dose combinations (FDCs) refer to products
5lood sugar to screen for.diabetes mellitus. containing two or more active ingredients in fixed doses,
Liver function test.
used for a particular indication(s).
00d urea and creatinine to assess kidney function.
In NTEP, for Adults 4-FDC (given in IP) consists
8. ne
-

examine routine and microscopic.

. regnancytest (for
Chest X-ray
all women in child bearing age group)
of HRZE and 3-FDC (given in CP) consists of HRE.
For paediatric patients dispersible 3 FDC consists of HRZ
-

Most and dispersible 2 FDC consists of HR.

patients on first line drugs complete their
efecte hout any serious drug side effects. Trivial side Aduantages of FDCs
treatment,
nence ast ato reduced compliance with the .Simpliçity oftreatment
Comm ptom-based approach to the management of the
On adverse effectshould be adopted .Increased patient acceptance
Pharm programme Fewer tablets to swallow
Phatmcobigilance inTBcontrol as Prevents 'concealed' irregularity
ance is defined by the WHO the sCience
218 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

Increased health worker compliance During treatment if the weight of the patient increas
Fewer tablets to handle, hence quicker supervision of more than 5 kg and crosses to the next weight band cated
DOT then patient should be given the next higher weight bandban
Easier drug management FDC drugs.
Reduced use of monotherapy Treatment of paediatric TB
-
Lower risk of misuse of single drugs
Paediatric cases are to be treated under NTEP in dail.
Lower risk of emergence of drug resistance
dosages as per 6 weight band categories. All adolescents
Easier to adjust dosages by body weight upto 18 years of age and weighing less than 39 kg, are to ho
Treatment is given in two phases (24): treated using paediatric weight bands and children eighing
more than 39 kg with adult weight bands.
Intensive phase (IP) consists of 8 weeks (56 doses) of
isoniazid (H), rifampicin (R), pyrazinamide (Z) and Key product information (for paediatric)
ethambutol (E) given under direct observation in daily 1. Dispersible FDC, flavoured
dosages as per weight band categories. Rifampicin 75 mg + Isoniazid 50 mg+
Continuation phase (CP), consists of 16 weeks (112 doses) Pyrazinamide 150 mg
of isoniazid, rifampicin and ethambutol in daily dosages. Rifampicin 75 mg + Isoniazid 50 mg
Only pyrazinamide will be stopped in the continuation
phase. The CP may be extended by 12-24 weeks in certain 2. Dispersible Loose drugs
forms of TB like CNS TB, skeletal TB, disseminated TB etc. Ethambutol 100 mg
based on clinical decision of the treating physician on case Isoniazid 100 mg
to case basis. Extension beyond 12 weeks should only be
on recommendation of specialists. Drug dosage for paediatric TB (24)
Treatment Treatment Weight Number of tablets (dispersible FDCs)
Type of TB case
regimen in IP regimen in CP category Intensive phase Continuation phase
New and previously treated cases 2 HRZE 4 HRE HRZ E HR E

(H and R sensitive/ unknown) 50/75/ 150 100 50/75 100

Prefix to the drugs stands for number of months. 4-7 kg
Loose drugs could be used as substitutions in case off 8-11 kg 2 2
adverse drug reaction or with comorbid conditions. 12-15 kg 3 3 3
Steroids as an adjunctive therapy is useful in patients 16-24 kg 4 4 4
with TB pericarditis and meningeal TB, with an initial high
dose tapered downwards gradually over 6-8 weeks.
25-29 kg L 3+1A* 3 3+1A* 3
30-39 kg 2+2A* 2 2 +2A 2
Drug dosages for first line anti-TB drugs =
A Adult FDC (HRZE 75/150/400/275; HRE = 75/150/275). Itis
Maximum in added in higher weight band categories i.e. > 25 kg as these children
Drugs Adults Children may be able to swallow tablets.
children
10 mg/kg daily 5 mg/kg daily Change in weight bands to be effective upon crossing of
Isoniazid 300 mg weight bands irrespective of the quantum of weight gain/los.
(7-15 mg/kg) (4 to 6 mg/kg)
Rifampicin
15 mg/kg daily 10 mg/kg daily
600 mg Pyridoxine may be given at a dosage of 10 mg per day to
(10-20mg/kg) (8-12 mg/kg) all children receiving INH containing therapy irrespective ot
35 mg/kg daily 25 mg/kg daily
2000 mg age group.
Pyrazinamide (30-40 mg/kg) (20-30 mg/kg)
Nikshay entry : Once the treatment regimen is finalized.
Ethambutol" 20 mg/kg daily 15 mg/kg daily |
1500 mg all patients should be initiated on treatment after open
(15-25mg/kg) (12-15mg/kg)
15 mg/kg daily
the treatment card and entries are done in Nikshay. MO-P
20 mg/kg daily 1000 mg
Streptomycin mg/kg) should ensure that the treatment details are entered
(15-20mg/kg)(15-20 Nikshay by the PHI staff. Nikshay entry should not Dea
is administered only in certain situations, like TB separate activity. All events starting from notification
Streptomycin
meningitis or if any first line drug need to be replaced due to ADR as treatment outcome are from Nikshay as it is integrated pa
l
per weight of the patient of documentation (24).
Ethambutol is given separately for children to monitor ophthalmic
ADR Follow-up of the treatment
There are two components of the follow-up:
Daily dose schedule for adults
a. Clinical follow up : It should be done at monthly intera
(as per weight bands) (24)
mprovement in chest symptoms, increase in weig
Weight Number of tablets (FDCs) may indicate good prognosis.
category Intensive phase HRZE Continuation phase HRE b. Laboratory inuestigations putum smear microscop or
75/ 150/ 400/275 75/150/275 should be done at the end of intensive phase and end IP
treatment. A negative sputum smear at the endof
25-34 kg indicate good prognosis. However, in the prescide
ce
35-49 kg clinical deterioration, the medical officer may dring
50-64 kg dur
repeating sputum smear microscopy e early
65-75 kg continuation phase. This will provide the patieind. At
275 kgL Opportunity to undergo drug susceptibility test
 TUBERCULOSIS 219

Grouping of medicines
recommended for use in
completion of the treatment, a sputum smear and/or
culture should be done for every patient, as culture is more longer MDR-TB regimens
Specific and sensitive compared to smear microscopy to Medicine
detect the presence of M.TB in biological specimens. Groups & steps
levofloxacin OR Lfx
Long term follow-up at the end of 6, 12, 18, and Group A: moxifloxacin Mtx
24 months should be done.
In presence of any clinical Include all three medicines Bdq
sputum microscopy and/or culture bedaquiline
Symptoms and /or cough, Lzd
should be considered (23). linezolid
Cfz
clofazimine
DRUG-RESISTANT TB Group B:
2. MANAGEMENT OF cycloserine OR Cs
Add one or both medicines Trd
Providing treatment to diagnosed DR-TB patients is terizidone
E
extremely important. lo begin with, only MDR-TB patients Group C ethambutol
Dim
were offered treatment with a standard second-line regimen. Add to complete the delamanid Z
Later, treatment with standard regimen was offered
to regimen and when Pyrazinamide
extensively drug resistant (XDR) TB patients and MDR-TB medicines from Groups A imipenem-cilastatin Ipm-Cln
Mpm
with additional resistance to fluoroquinolones or second-line and B cannot be used OR meropenem
injectable. Procurement and supply chain management of amikacin Am
(S)
second-line drugs iS complex, since no standardized patient- (OR streptomycin)
and drugs do need ethionamide OR Eto
wise boxes are manutactured
temperature regulated storage and repacking. prothionamide Pto
p-aminosalicylic acid PAS
Since 2016, new drugs like Bedaquiline (Bdq) are made
accessible to DR-TB patients through expanded access under Source: (37, 24)
NTEP In 2016, with the release of the Revised Technical and
Operational Guidelines, regimens to treat other forms of Pretreatment evaluation for drug-resistant
drug resistance, such as mono and poly resistance to first patients
and second-line drugs were also included.
Since the drugs used for the treatment of DR-TB have
is
Guidelines for PMDT TB (2019) significant adverse effects, a pretreatment evaluation
essential to identify patients at increased risk of developing
In 2019 the WHO published consolidated guidelines on
the treatment of drug resistant TB. It has substantially such adverse effects. This pretreatment evaluation is as
changed the approach to the treatment of MDR/XDR-TB. follows:
includes (24, 36)
Pretreatment evaluations
policy recommendations on treatment regimens for Detailed history (including screening for mental
isoniazid resistant TB and multidrug and rifampicin illness, seizure disorder, drugalcohol abuse, etc.)
resistant TB (MDR/RR-TB), including longer and shorter
Previous history of ATT taken especially SLI/FQ
regimens;
culture monitoring of patients on treatment; Weight& height
MDR/RR-TB Thorough clinical examination
the timing of antiretroviral therapy in
patients infected with HIV; Complete blood count with haemoglobin &
MDR-TB platelets count
the use of surgery for patients receiving
treatment; and Blood sugar to screen for Diabetes Mellitus
optimal models of patient support and care. Blood urea and S. Creatinine to assess renal function
According to the 2019 consolidated guidelines, fully oral Urine examination -routine and microscopic
regimens should have priority and should become an 9 UPT (for all women in the child-bearing age)
option for most patients. Injectable agents should no longer 10 Chest X-ray
De among the prioríty medicines for designing longer 11 HIV counselling and testing'
MDRTB regimens.
12 Audiogram
If needs to be emphasized that treatment for drug resistant Liver function tests"
Bshould only be provided under the supervision of an or
13
perienced doctor. This includes the choice of a shorter 14 TSH levels to assess the thyroid function
1onger regimen, and also whether injectable drugs are used. 15 Mental health evaluation
Accordingly, India has made some changes in its 16 Surgical evaluation
MDT guidelines. The revised integrated DR-TB diagnostic 17 ECG (if Mfx, Dlm, Bdq, Ctz used)
digorithm recommends testing of all TB patients for 18 Serum electrolytes- potassium, magnesium, calcium
for
ampicin and isoniazid resistance and all RR-TB patients Serum proteins, lipase, amylase
uoroguinolone and second line injectable. Fig. 3 on 19
age 220 shows the integrated drug resistant TB 20 Ophthalmologist opinion to rule out
chorioretinitis/uveitis
algorithm(2019)
MDR-TB All DR-TB patients will be offered referral for HIV counselling and
he medicines recommended for longer testing at the nearest centre if the HIV status is not known or HIV test
mens are classified into three groups (A, B and C) based
class and aligned result is negative with results more than 6months old. If patient is HIV
ticaey, experience of use and drug positive, refer to ART centre (if not on ART)
revised classification as per WHO consolidated including HBsAg at baseline
udelines for treatment of drug resistant TB. The groups are
aslisted below Source: (24)
220 EPIDEMIOLOGY
OF COMMUNICABLE DISEASES

Presumptive TB
All notified TB patients
;7 H
E Non responder
to treatment

PLHIV.
EPTB NAAT
Smear -ve/NA with DS TB
X-ray suggestive of TB Hmono/poly
including paediatric
Vulnerable populations
R resistance detected
Contact of DR TB patient R resistance not detected

FL, SL-LPA & LC DST| First line treatment

FLLPA
Presence of non DST based criteria &/or
Lfx/Mfx(h), Km/Cm/Am &/or InhA Resistance to
mutation detected
No Unknown Yes
H resistance Hresistance
History of use for > 1
month/intolerance to detected not detected
Mfx(h), Km, Eto or Cfz
No Yes SL LPA & LC DST
In case of additional resistance,
Shorter failing regimen, drug intolerance All oral
MDR TB
regimen
returnorafter interruption (>1m) longer
emergence of any
MDR | All oral H mono/poly
Continue first-line treatment
exclusion criteria
TB regimen DR
L
TB regimen

NAAT include CBNAAT & TruNAAT Modify regimen

LC DST will be done as per the diagnostic algorithm

FIG.3
Integrated drug resistant TB algorithm (2019)
Source: (24)

Pretreatment evaluation and treatment initiation must be
done at the DR-TBC (Drug-Resistant TB centre) i.e., DDR-
TBC (District DR-TBC) and NDR-TBC (Nodal DR-TBC).
The concerned DR-TBC committee provides counselling,
initiates activities related to active drug safety monitoring
(aDSM) like, assessing the baseline history of known
adverse/serious adverse events, biochemical investigations,
ECG etc., and initiates him/her on an appropriate treatment
regimen. Care must be taken to correct any electrolyte
imbalance before treatment initiation.
MDR/RR-TB patients (without additional resistance) and
H mono/poly DR-TB patients can be initiated on a standard
treatment regimen at DDR-TBC. The DDR-TBC should refer
patients to NDR-TBC for management of additional drug
resistance, drug intolerance, contraindication, failing
regimen, return after treatment interruption of >1 month,
emergence of exclusion criteria for standard regimen, for
expert opinion, management of any complications
warranting regimen change for consideration of newer drug
containing regimen or DST guided regimen based on a
detailed assessment.
Providing health education and counselling to patient
and family members (23)
All MDR-TB cases are offered referral for counselling and
HIV testing at the nearest centre. Patients should receive
counselling on the nature and duration of treatment, need
for regular treatment and possible side effects of these drugs
and the consequences of irregular treatment or pre-mature
cessation of treatment and cough etiquette. It is advisable to
involve close family members during the counselling, since=
family support is an essential component in tn
management. Patients should be advised to report any side
eifects experienced by them. Female patients should receives
special counselling on family planning.
While the MDR-TB case is undergoing pre-treatmen
evaluation, the DTO should ensure an initial home visitt
verify theaddress and meet the family members. n
medical officer needs to open a treatment card for
patient at the time of initiating the treatment. Each patier
must be given TB Identity Card. A DOT provider(whoea
either be a health care worker or a community volunte
should be identified in consultation with the patient.
DOr centre can be either at the sub-centre of the n
system or in the community. The DOT provider shou
given training for drug administration, identificato
adverse effects during treatment and the frequeny
follow-up.
R
Under NTEP, the. following are the standara
regimens:
1. All oral H mono/poly DR TB regimen
2. Shorter MDR TB regimen
3. All oral longer MDR TB regimen
 TEURERCULOSIS
221
tandard regimen for initiating treatment of can be providecd to the patient 218 yrs} for children
&
IDR/RR TB or H mono-poly DR TB adolescents between 6 to 17 years, Dln can be

îegimen class Intensive phase

provided. Use of Bdq for 6 to 17 yrs and Dlm for 3 to
Continuation phase 6yrs may be considered only after approval of
DCGI.
mono/poly DR TB R resistance not detected and H resistance)
non-pregnant females or females not on hormonal birth
All oral H
mono-poly| (6) Lfx REZ They should be willing to
control methods are eligible.
R-TB regimen" Continue practicing birth control methods throughout the
DR RR TB
freatment period or have been post-menopausal for past
Shorter MDR TB (4-6) Míxh Km/ 5 Mfxh Cíz 2 E 2 years; and
Am' EtoCfz Z Hh E
egimen" patients with controlled stable arrhythmia can be
All oral longer (18-20) Bdq (6) Líx Lzd" Clz Cs considered after obtaining cardiac consultation.
MDR TB regimen"

l the intensive phase is prolonged, the injectable agent is only given Exclusion criteria for newer drugs (Bda/DIm)
three times a week in the extended intensive phase. Pregnancy & lactating mother
# Reduce Lzd to 300 mg/day after 6 to 8 months.
currently having uncontrolled cardiac arrhythmia that
a Pyridoxine to be given to all DR TB patients as per weight band.
requires medication;
Alloral H mono/poly DR TB regimen is of 6 months with no separate having any of the following QTcF interval characteristics
IP'CP
- Shorter MDR TB regimen is of 9-11 months with 4-6 months of IP
at screening:
containing injectables and 5 months of CP QTcF 2500 at baseline & normal electrolytes. ECG to be
-lfthe IP is prolonged, the injectable is only given three times a week repeated after 6 hours and if both ECGs show
in the extended intensive phase. QTcF>500 then the patient should not be challenged
- All oral longer MDR TB regimen is of 18-20 months with no with cardiotoxic drugs.
separate IP/CP
Newer drugs like Bdq and Dlm would be given for 6 months
history of additional risk factors for Torsade de Pointes
duration while the dose of Lzd will be tapered to 300 mg after the e.g. heart failure, hypokalaemia, family history of long
initial 6-8 months of treatment. QT syndrome.
- This regimen will also be used for treatment of XDR TB patients with
20 months duration. Dosage of DR TB drugs
Source: (24) The dosage for drugs used in various DR TB regimens by
weight bands for adults are enumerated in Table 2. These
Inclusion criteria for newer drugs (Bdq/DIm) are in accordance to the WHO recommended doses of
Patient aged >6 years having MDR/RR TB. (Bdq/DIm anti-TB drugs for ac and paediatric patients.
TABLE 2
Dosage of DR TB drugs by weight bands
S.No. Drugs 16-29 kg 30-45 kg 46-70 kg 70 kg
Rifampicin (R) 300 mg 450 mg 600 mg 750 mg
2 High dose H (H') 300 mg 600 mg 900 mg 900mg
3 Ethambutol (E) sg 400 mg 800 mg 1200 mg 1600 mg
4 Pyrazinamide (Z) 750 mg 1250 mg 1750 mg 2000 mg
Levofloxacin (Lfx) 250 mg 750 mg 1000 mg 1000 mg
Moxifloxacin (Mfx) 200 mg 400 mg 400 mg 400 mg
High dose Mfx (Mfxh) 400 mg 600 mg 800 mg 800 mg
Bedaquiline (Bdq) Week 0-2: Bdq 400 mg daily
.
Week 3-24: Bdq 200 mg 3 times per week
Linezolid (Lzd) 300 mg 600 mg 600 mg 600 mg
10 Clofazimine (Cfz) 50 mg 100 mg 100 mg 200 mg
11 Cycloserine (Cs) 250 mg 500 mg 750 mg 1000 mg
12 Delamanid (Dim) 50 mg twice daily (100 mg) for 24 weeks in 6-11 years of age
1 100 mg twice daily (200 mg) for 24 weeks for >11 years of age
mipenem/cilastatin (Ipm/Cls)4 1 1000 mg imipenem/1000 mg cilastatin twice daily
14 Meropenem (Mpm) 1000 mg three times daily (alternative dosing is 2000 mg twice daily)
15 Amikacin (Am 500 mg 750 mg 750 mg 1000 mg
16 Capreomycin (Am)2
17 Kanamycin (Km) 500 mg 750mgidiiei 750 mg 1000 mg
mg mg 750 mg
18 Ethionamide (Eto) 375gm 500 1000 mg
10 14 gm 16 gm 22 gm
19 NaPAS (60% weight/vol)*
875/125 mg
20Amoxyclav (Amx/Clv)(In child: 875/125 mg 875/125 mg 875/125 mg
BD (2 morning + 1 evening) (2 morning + 1 evening)
WHO 80 mg/kg in 2 divided doses) BD
yridoxine IPdx) 50 mg 100* mg 100 mg 100 mg
.For H mono/poly resistant T5 age,
adult more than 60 years of dose of SLI should be reduced to 1Omg/kg (max upto 750 mg)
12 gm (46-70 kg) and 16 am (>70
patientof PAS with 80% weight/volume the dose will be changed to 7.5gm (16-29kg); 10gm (30-45 kg); kal
rugs can be given in divided doses in a day in the event of intolerance
Source: (24)
 COMMUNICABLE DISEASESS
222 tEPDEMIOLOGY OF
LPA and Sl. LPA and culture DST
1
patient to FL prolon
Bedaquiline (24) additional resistance is detected, tnethne iP should be nged
smear converts. intensive phaso
Week 0-2 Bdq 400 mg (4 tablets of 100 mg) daily until sputum timo.
agent is only given three
3-24: Bdq 200 mg
days per week)+ other drugs; Weekweek prolonged, the injectable or 6th month based
of 100 mg) 3 times per (with at least week. IP should be extended to bth month of treatmo
tablets
48 hours between doses) for a total dose of 600 mg
per smear results at the end ot 4th and sth
7) to end a maximum ot 2 months (i.e.. total
week + other drugs; and Week 25 (start of month This will be done for
Duration of CPis
O1 treatment: Continue other second-line
anti-TB drugs only duration of IP is not more than b months). smear
If the patient remains positive at
as per NTEP recommendations. fixed for 5 months.
or treatment, the patient will be
If taking a light meal with Bdq and other anti-iE drugs, the end of 6th month
at the declared as "Treatment railure, re-evaluated as Der
patients should not consume milk-containing products initiated on an appropriate
same time, as the calcium in these can decrease ihe integrated DR TB algorithm and DST.
fatty meals should be modified regimen based on the extended
absorption of FQs. Also, large the other
absorption of some of
avoided, as these can impair All oral longer MDR TB regimen
anti-TB drugs (Cs, H, etc.). MDR TB regimen IS
during the Total duration of all oral longer
The following medications are disallowed 18-20 months. At the end of bth month ot treatment, the
Bdq and upto one month after the
24-week administration of patient must be reviewed based on the sth month culture
potential drug-drug interactions:
last dose of Bdq because of result. 5th month
If culture result is not available at the end
CYP3A4 inhibitors,
systemic use of moderate and strong of 6th month, deCISion to tapper the dose ot Lzd to half
ketoconazole, voriconazole,
(300/150 mg) will be based on 4th month culture result.
If
e.g. azole antifungals:
ketolides such as telithromycin (whichever applicable)
itraconaz0le, fluconazole; the 5th or 4th month culture result
antibiotics other than azithromycin for mg) and the
and macrolide remains positive, the dose ot Lzd (6U0/300 owever, the
more than 2 consecutive weeks more month.
regimen is extended by l
systemic use of strong CYP3A4 inducers, e.g. phenytoin, duration of new drugs (Bdq or Dim) limited
is to 24 weeks
wort and
carbamazepine, phenobarbital, St. John's only. Decision for continuation of extended
IP with zd
ritamycins (rifampin, rifabutin, ritapentine); and is decided based on the
class.
(600/300 mg) beyond 7th month,
clinical/radiographic
cholesterol lowering medications of the "statin" culture results of 6th/5th month and the
is not
response. Extension of lP beyond 8th month
Delamanid (24) permitted and patient should be switched
to CP (i.e. total
Delamanid months).
Allpatients > 12 yrs of age will receive Tab.
a day for
duration of treatment is not more than 20
100 mg (two tablets of 50 mg) orally twice
If the patient continues to remain culture positive
or

24 weeks in combination with other drugs in the regimen after 8 months of treatment.
to 6 to 11 yrs of age group will reverts back to culture positive
while patients belonging re-evaluated as
mg) twice a the patient is declared as "Treatment failed",
receive Tab. Delamanid 50 mg (one tablet 50
of on an
in regimen will be per integrated DR TB algorithm and initiated
day for 24 weekS. Remaining drugs on the extended DSI.
appropriate moditied regimen based
continued beyond the 24 weeks of Dim administrationIt foris For XDR TB patients the duration of all oral longer MDR 15
treatment.
the NTEP recommended duration of regimen would be for 20 months.
important that Dlm be taken daily preferably after a
standard meal to improve bioavailability.
Treatment Interruptions & DRTB
Patients should not consume milk-containing products at
the same time, as calcium can decrease the absorption
of Management of DR TB patients with treatment
as these
FQs. Also, large fatty meals should be avoided interruptions and lost to follow-up
can impair absorption of some of the other anti-lB drugs All efforts must be made to ensure that DR
TB patiets co
(Cs, H, etc). Action shoud
not interrupt treatment or are lost to follow-up.
Extension of treatment in various DR TB be taken to promptly retrieve patients who tail to come
The tollow
regimens (24) their daily dose by the treatment supporter.
Strategies àre applicable for patients who interrupt treaten
All oral H mono-poly DR TB regimen Patients who miss doses : In shorter MDR TB regimen.
du

Total duration of Hmono-poly DR TB regimen is
6 months, can be extended to 9 months in certain conditions.
In patients with extensive disease; uncontrolled comorbidity;
extra-pulmonary TB; if smear at the end of 4th month is
found positive, the regimen 1s modified, the
treatment may
TB,
be extended to 9 months. In CNS, skeletal and milliary
treatment may be given up to a year. In patients who remain
sputum smear poSitive at the end of 5 month or later of
treatment, the outcome will be declared as treatment failure.
Shorter MDR TB regimen
Total duration of shorter MDR TB regimen is for
9-11 months, depending on lP duration. IP should be given
missed doses during IP must be completed prior to st
the patient to CP Similarly, all missed doses during C
In longer i
be administered prior to ending treatnment.
TB regimen, all missed doses during treatment
mu be
administered prior to ending treatment.
Patients who interrupt treatment for less than onetment
wnen the patient returns to resume treatment, tne redill
will be continued. However, the duration of treatrou
be extended to complete the regimen. The o
Cultures will be done as per the schedule. eatment
Patients who are "lost to follow-up" (interruptack
continuously for one month or more) and retu ost to

for at least four months. After fourth month of treatment,

if treatment: Such patients will be given an outconNAAT
the result of sputum microscopy is negative then CP should Tollow-up. The patient would be subjected to repeathm to
If sputum smear microscopy does not become
be initiated. FL/SL LPA and LC DT as per the diagnostic signs o
are >*s
negative by the fourth month of treatment, subject the estart with appropriate treatment. lf there
 TUBERCULOSIS 223
oending treatment1failure for any MDR RR TB patient with will be
ar without additional ifinterruption is more than one month, Bdq
resistance to second line drugs, permanently discontinued. Such patients will be given
afient should be Switched to an all oral longer DR the TB an outcome of "Lost to follow-up (LTF0), registered
imen and evaluated further to modify appropriately based afresh and initiate all oral longer MDR TB regimen
with
n DST results it required. Ifa patient has received the shorter appropriate modification. A sputum specimen will be
MDR TB regimen tor more than
one month isolate must be stored
oatment after an interruption of one monthandor returns for collected for culture. The culture
more, the for Bdq DST in future
patient is not restarted on a shorter MDR TB regimen.
Delamanid If the patient misses one or more doses of
MDR/RR TB patients on Bdq/DIm containing one
regimen Dim during treatment upto a maximum of one month,
oho interrupt treatment or are "lost to follow-up" Dlm for rest
or should continue the treatment and complete the
recurrentDR TB: of the period which may prolong the Dlm containing phase
Patients who interrupt Bedaquiline treatment during the beyond 24 weeks from initiation of treatment to make the
first two weeks of Bdq course and return to resume the adjustment of missed dosage.
treatment: Patients who initiated on Bda/DIm containing regimen
if interruption is upto 7 days, Bdq containing regimen and return after treatment interruption of one month or
continued to complete the doses and the duration
will be more will be declared as "lost to follow-up". Such patients
of treatment will be extended to complete IP. Follow-up would not be considered eligible for administration of same
cultures will be done as per the revised schedule; and drug (Bdq/Dlm) anymore.
if interruption is more than 7 consecutive days, Bdq Where further treatment is concerned, if the patient has
course will be reloaded (started afresh) and a fresh any indication of a treatment failure or recurrence, the NDR
specimen collected for culture. The culture isolate must TBC Committee will be contacted to discuss whether s/he
be stored for Bdq DST in future should be retreated. The decision will be made on a case-to
Patients who interrupt Bedaquiline treatment during
case basis, using all available bacteriological and clinical
data.
3-24weeks of Bdq course and return to resume treatment (24)
if interruption is upto one month, Bdq containing regimen Follow-up evaluations during treatment (24)
will be continued to complete the doses and duration of The follow-up evaluation schedule during treatment for
treatment will be extended to complete full course of Bdq. DR TB patients managed with various regimen classes are
Follow-up cultures will be done as per revised schedule; and summarized in the Table 3.
TABLE 3
Follow-up evaluation schedule of DR TB patient during treatment by regimen
Regimen class All oral regimen for Shorter MDR TB All oral longer
HMono/Poly DR TB regimen regimen for MDR/RR
Duration 6/9 months (no separate IP/CP) 9-11 months (4-6m IP, 5m CP) 18-20 months (no separate IP/CP)
Clinical+ Wt. Monthly Monthly in IP Monthly in first 6 months
quarterly in CP Quarterly beyond 6 months
Smear Monthly from 3rd Monthly from 3rd month onwards With culture at C-DST labs
microscopy month onwards till end of IP, monthly in extended
IP only if previous month S+ve
Culture At end of 3rd, 6th and 9th At 3rd, 6th and end of Rx Monthly from 3rd month onward to
month (if applicable) end of 6 months. Quarterly beyond
6 months, 2 consecutive monthly culture
if any culture +ve from 6m onwards
DST NAAT, SLLPA and LC DST FL& SL LPA and LC DST (Mfx 1.0, Lzd FL& SL LPA and LC DST (Mfx 1.0, Lzd,
as per algorithm if smear/culture Cíz & Z) if any culture +ve (3rd, 6th and Cfz, Bdq & Dlm) if any timne culture +ve
+ve at 3rd, 6th and/or 9th month end of Rx) or smear +ve at end of IP at end of 6 months or beyond 6 months
end of extended IP and end of Rx
S. Creatinine Monthly till SLI course is If injectable is used, monthly till SLI
completed course is completed
Audiometry Every 2 months till SLI course is If injectable is used, every 2 months till
completed and then as and when SLI course is completed and as and when
clinically indicated linically indicated
UPT As and when clinically indicated As and when clinically indicated As and when clinically indicated
CBC/platelets As and when clinically indicated As and when clinically indicated 15th day, monthly in first 6 months, then
as and when clinically indicated
TSH& LFT At end of IR, then as and when LFT quarterly, as and when
As and when clinically indicated
clinically indicated clinically indicated
CXR As and when clinically indicated At end of IP end of treatment, then as At the end of 6 months, end of treatment,
and at end of Rx and when clinically indicated as and when clinically indicated
ECG As and when clinically indicated At 2 weeks, monthly in IP, then as and At 2 weeks, monthly in first 6 months,
then
when clinically indicated as and when clinically indicated
S.Electrolytes As and when clinically indicated As and when indicated and in case of As and when indicated and in case of
Na, K, Mg. Ca) any QTcF prolongation any QTcF prolongation
Specialist As and when clinically indicated As and when clinically indicated As and when clinically indicated
consultation
Colour vision test Once in two months (in children) Ophthalmic exam once in 3 months
Once in two months (in children)
Source (24)
224 EPIDEMIOLOGY OF COMMUNICABLE DISEASES

CHILDHOOD TUBERCULOSIS strategy comprises of components. First, as in adults, childo

Cases of tuberculosis in children usually represent
between 6-8 per cent of all tuberculosis in the age group of
under 15 years (4). The source of infection to a child is
usually an adult, often a family member with sputum smear
positive tuberculosis. The frequency of childhood TB in a
given population depends on: (a) the number of infectious
cases; (b) closeness of contact with an infectious case;
(c)the age of child when exposed to TB; and the age
structure of the population.
Children rarely have sputum smear-positive TB and it is
unlikely that they area powerful source of transmission of TB.
Tuberculosis in children is mainly due to failure of TB control
in adults. The risk of infection to a child depends on extent of
exposure to infectious droplet nuclei. An infant whose mother
has sputum smear-positive PTB has a high chance of
becoming infected. The chance of developing disease is
greatest shortly after infection, and steadily decreases as the
time goes by. Because of less-developed immune system,
children under 5 years of age are more prone to develop
(upto 20 per cent) the disease mostly within 2 yearsfollowing
infection (26). The commonest age of childhood TB disease
is 1 to 4 years. Young age is a risk factor for spread of disease
to other parts of the body, i.e. dissemination.
In order to simplify the management of paediatric TB,
RNTCPin association with Indian Academy of Paediatrics
(1AP) has described criteriaforsuspecting TB among children,
has separate algorithms for diagnosing puimonary TB and
peripheral TB lymphadenitis and a strategy for treatment and
monitoring patients who are on treatment. In brief, TB
diagnosis is based on clinical features, smear examination of
sputum where this is available, positive family history,
tuberculin skin testing, chest radiography and histo
pathological examination as appropriate. The treatment
with TB are classified, categorized, registered and treated u
en
daily dose short-course chemotherapy from treatmen
initiation to completion, given under direct observation of a
treatment provider (DOT provider) and the disease statis is
monitored during the course of treatment. Based on theirpre.
treatment weight, children are assigned to one of the pre
treatment weight bands and are treated with good quality anti
TB drugs through "ready-to-use fixed dose combination
tablets in patient-wise boxescontaining the patients' completo
course of anti-TB drugs, made available to every registered TB
patient according to programme guidelines. India i
the first country to introduce paediatric patient-wise boxes (4
Diagnosis of Paediatric TB
In children with presumptive paediatric TB, every attempt
must be made to microbiologically prove diagnosis through
examination of appropriate respiratory/non-respiratory
specimens with quality assured diagnostic tests. Diagnosis of
tuberculosis should not be made only on clinical features,
and further investigations are always necessary to establish
the diagnosis.
In case of suspicion of pulmonary TB, sputum
examination should be carried out among children who are
able to give good quality specimens. CBNAATis the preferred
investigation of choice. If CBNAAT is not readily available or
testing is not possible even by referral, smear microscopy
should be performed. If M. tuberculosis is detected, by either
of methods patient is diagnosed as microbiologically
confirmed pulmonary TB. In situations where M. tubeculosis
is not detected or specimen is not available, chest X-ray and
Tuberculin skin test (TST) by Mantoux technique using 2 TU
of PPD RT 23 should be done. For interpretation and further
course of action, refer to the diagnostic algorithm tor
childhood pulmonary TB (Fig. 4).

Persistent Fever 2 2 weeks, without a known cause and/or

Unremitting cough for 22 weeks and/or
Wt loss of 5% in 3 months or no wt gain in past 3 months

CBNAAT (on sputum)

*If CBNAAT isnot readily available smear
microscopy should be performed

MTB not detected OR sputum not available

MTB detected X-Ray and TST

XRC highly CXR NS shadows CXR normal CXR normal

Microbiologically TST ve
confirmed TB case Suggestive TST-ve TST+ve

Gastric aspirate/induced Give course of Evaluate for EPTB.

sputum for CBNAAT antibiotics Kerer to expert

Persistent shadow Look for

Ve e and symptoms alternate cause

Gastric aspirate/induced
No other likely alternative diagnosis sputum for CBNAAT
clinically diagnosed 1TB case

e Ve
Refer to expert for work-up
of persistent pneumonia
FIG. 4
Diagnostic algorithm for paediatric pulmonary TB
Source: (23)
 TUBERCULOSIS 225
medication to
lo following
the flow chart, it is important to note the an expert; (2) Include at least 4-6 bactericidal susceptible;
likely to be
followingpoints: which the strain is known to or
failing regimen; (4) Ensure
10 alaorithm children who are likely to have drug
is for ) Do not add a single drug to12a months after M.TB culture
e disease i.e.
have not received AlT previously reatment is given for at least treatment to
ouer and are not presumptive drug resistant TB cases nas converted to negative; and extend
cavitatory lesions.
lost to folow-up, reCurrent, freatment failure, HIV). 24 months in case of HIV infection or
designs without
9Proper characteri2ation of symptoms is very important The children are managed with regimen for
sarting point. Weight loss or not gaining weight should newer drugs, depending on the DST pattern. The dosage for
always be documented with appropriate and proper DR-TB regimens by weight bands
drugs used in various
paediatric DR-TB patients are enumerated in Table (38)
4
weighing.
CBNAAT is doable, smear examination may not TABLE 4
Where
ho done. Whenever smear is used for diagnosis at least
WHO recommended doses of
2 samples should sent while a single sample is
be anti TB drugs for paediatric patients
subiected to CBNAAT. If a specimen is positive by any of
methods, the disease is labelled as Drugs Daily Dose (Paediatric)
these
microbiologically confirmed TB. Isoniazid 1 7-15 mg/kg for patients less than 30
kg:

4. Highly suggestive
chest X-ray refers to skiagrams max dose 300 mg daily
kg:
showing either miliary or lymphadenopathy (hilar or Rifampicin 10-20 mg/kg for patients less than 30
mediastinal) or chronic fibr0-cavitatory shadows. If the max dose 600 mg daily
kg:
radiological picture is highly suggestive of TB, then Pyrazinamide 30-40 mg/kg for patients less than 30
max dose 2000 mg daily
proceed to do further investigations irrespective of the
Ethambutol 15-25 mg/kg once daily
TST result as the sensitivity of the test is not 100%.
Levofloxacin 5 years and under: 15-20 mg/kg split into
5. Non specific chest X-ray : Refer to patterns other than two doses (morning and evening)
highly suggestive like consolidations in homogenous Over 5 years: 10-15 mg/kg once daily
shadows or bronchopneumonia, etc. Moxifloxacin 7.5-10 mg/kg
6. Whenever indicated, alternative specimens (gastric Ethionamide/ 15-20 mg/kg
aspirate/induced sputum/bronchoalveolar lavage) should Protionamide
be collected by a skilled health care provider, depending Cycloserine 10-20 mg/kg
upon available infrastructure and sample should be P-aminosalicylic 200-300 mg/kg for patients
subjected to CBNAAT acid less than 30 kg
10 mg/kg given three times daily
Antibiotics like linezolid or any quinolone or Amoxicillin-
7.
Linezolid
(pyridoxine should also be given)
clavulanic acid should not be used as they have anti-TB Limited data, but 1 mg/kg once
Clofazimine
action. daily has been given
8. Children with persistent symptoms, non specitic shadows Amoxicillin 80 mg/kg (based on the amoxicillin
(GA/IS)
and negative smears and negative other samples clavulanic acid 7/1 component) in two divided doses
by CBNAAT should be referred to experts for further Kanamycin 15-30 mg/kg once daily (Max 1000 mg)
work-up of persistent pneumonia. Amikacin 15-30 mg/kg once daily (Max 1000 mg)
9. All TB cases diagnosed must be offered testing for HIv. Capreomycin 15-30 mg/kg once daily (Max 1000 mg)
10. Whenever Rif resistant result is reported on CBNAAT Imipenem cilastatin Meropenem is preferred in children
Turther management should be carried out as per the Meropenem 20-40 mg/kg intravenous every
eight hours
guidelines on drug resistant TB. Refer to page 222
Bedaquiline
TBpreventive therapy Delamanid Refer to page 222
. he dose of INH for chemoprophylaxis is 10 mg/kg 1
Children at risk for peripheral neuropathy (e.g. malnutrition or
tanstead of earlier recommended dosage of mg/k9 HIV co-infection) should also receive pyridoxine 5-10 mg'day as
therap
uinistered daily for 6 months. TB preventive therapeutic dose.
should be provided to: Source: (38)
of a
asymptomatic contacts (under 6 years of age)
near positive case, after ruling out active disease and TB IN PREGNANCY AND LACTATING
Lrespective of their BCG or nutritional stafus. WOMEN (23)
hemoprophylaxis is also recommended for all iv Before initiating treatment for tuberculosis, wome of
exposure to an childbearing age should be asked about current or planned
ected children who either had a known (TST) positive
pregnancy and counselled appropriately. A successful
us TB case or are tuberculin skin test
o mm induration) but have no active T5 are disease. treatment of TB is important for successiul outcome of
C.ATST positivechildren who receiving pregnancy. With the exception of streptomycin, the first line
nosuppressive therapy (e.g. children with nephrotic anti-TB drugs are sate for use in pregnancy. Streptomycin is
ndrome, acute leukemia, etc). TBB
oto-toxic to the toetus and should not be used during
Achild born to mother, who was diagnosed to have pregnancy.
pregnancy 6 months,
in Snouid receive prophylaxis for oy A breast feeding woman should receive a full course of
Provicto ruled out followea TB treatment. Correct chemotherapy
is the best way to
RCd congenital:TB has been
vaccination prevent transmission ot TB to baby. Breast feeding has to be
g-resistant TB children continued. After ruling out active TB, the baby should be
in given 6 months of isoniazid preventive therapy,
followed by
drug-resistant TB in BCG vaccination. Breast-teeding should not be discouraged.
childrennciples of treatment of with
Always treat the child in consultation
 EPIDEM1oLOGY OF COMMUNICABLE DISEASES
226 BCG VACcCINATION
hygiene
The mother should be advised about cough M. tuberculosis, attemnt.
measures such as covering the nose and mouth while Ever since Koch discovered
Coughing. sneezing or any act which can produce
sputum prepare a prophylactic vaccine againe
infants have been made to or killed fubercle bacill
droplets. Mothers receiving INH and their breastfed
(pyridoxine).
tuberculosis using either attenuated 1921 to 1925. The first
should be supplemented with vitamin B Initially BCG was given orally during
intradermal technique
Recommended dose of Pyridoxine in infants is 5 mg/day. human was vaccinated by theof BCG came in 1948 uhnen
1927, Recognition of the value
Pregnancy with MDR-TB it was accepted by tuberculosis
workers from all over the
preventive measure.
All MDR-TB suspects and patients of child-bearing age world as a safe
should be tested for pregnancy as part of pre-treatment
is to induce a
(1) AIM The aim of BCG vaccinationwill stimulate
evaluation and while on treatment, if there is a history of to benign, artificial primary intection which an
infection
amenorrhoea of any duration. They should be advised risk to acquired resistance to possible subsequent with
potential morbidity and
use birth control measures because of the virulent tubercle bacilli, and thus reduce the
both mother and foetus. Oral contraceptives should be mortality from primary tuberculosis among those most at risk
avoided. Use of barrier methods (condoms/diaphragms), (2) VACCINE BCG is the only widely used live bacterial
TUDs are recommended, based on individual preference and living bacteria derived from an
eligibility. The management of MDR-TB patients with vaccine. It consists of
attenuated bouine strain of tubercle bacilli. The bacilli used
pregnancy is summarized in Fig. 5.
for vaccine production are descendants of the original
Pregnant DR-TB patients need to be monitored carefully, Calmette strain of BCG. Due to ditferent methods of
both in relation to the treatment and progress of the maintenance in various vaccine-production laboratories,
pregnancy. This approach should lead to good results, since many substrains have evolved during the past tew decades.
the patient should be smear-negative at the time of The WHO has recommended the Danish 1331" strain for
parturition and mother and infant do not need to be the production of BCG vaccine. Since January 1967, the
separated. Breast-feeding should be encouraged as long as BCC Laboratory at Guindy, Chennai, has been using the
the patient is sputum negative "Danish 1331" strain for the production of BCG vaccine
In the end it may be stated that the main problem of (39). Emphasis has been laid on regular checking of the
chemotherapy today is not the need to introduce new quality of vaccines at the International Reference Centre for
regimens or more potent drugs, but to apply the existing BCG quality control at Copenhagen.
ones successfully. The cornerstone of successful (3) TYPES OF VAcCINE There are two types of BCG
chemotherapy is adequate and regular drug intake. Patient vaccine the liquid (fresh) vaccine and the freeze-dried
compliance is critically important throughout the prescribed vaccine. Freeze-dried vaccine is a more stable preparation
period of treatment. All other considerations are secondary.
than liquid vaccine with vastly superior keeping qualities
Present-day vaccines are distributed in the freeze-dried form.
Duration of pregnancy BCG vaccine is stable for several weeks at ambient
temperature in a tropical climate, and for up to 1 year if kept
away from direct light and stored in a cool environment
preferably refrigerated at a temperature below 10 deg C (40)
The vacine must be protected from exposure to light
20 weeks 20 weeks during storage (wrapped up in a double layer of red or black
cloth) and in the field. Normal saline is recommended as a
diluent for reconstituting the vaccine, as distilled water may
Advised MTP
cause irritation. The reconstituted vaccine may be used up
within 3 hours, and the left-over vaccine should be discarded.
(4) DOSAGE: For vaccination, the usual strength
0.1 mg in 0.1 ml volume (41). The dose to newborn aged
MTP done Patient unwilling for MTP
below 4 weeks is 0.05 ml. This is because the skin ot
newborn is rather thin and an intradermal injection with fuu
dose (0.l ml) in some of them might penetrate into deepe
Start/continue Start/continue Start/continue tissue and give rise to local abscess
shorter modified conventional modified conventional formation and entargeu
MDR-TB
regional (axillary) lymph nodes.
regimen MDR-TB regimen
regimen (5) ADMINISTRATION
<12 weeks: Omit .Omit Km; add PAS The standard procedute
Km and Eto; till delivery recommended by WHO is to inject the vaccine intrader
add PAS using aluberculin syringe (Omega microstat syringe tite
.Replace PAS with
12 weeks: Omit With a I cm steel 26 gauge
Km after delivery intradermal needle). The syr
Km only; add PAS and continue till and needle technique remains the most precise wa
Replace PAS with end of IP administering the desired
Km after delivery (e.g., bifurcated needle, dose. All other
dermo-jet) are reported
tecnss
and continue till accurate, and do not permit cted
end of IP (+2).
the desired dose to be mje
It the vaccine is
more likely to developinjected subcutaneously an absces
(43). The site of injection
FIG. 5 Just above the insertion
of the left deltoid muscle stit is
Management of DR-TB patients with pregnancy injected too high, too forward ont
Source: (38) lymph nodes may become
injection should produce
or too backward, the
involved
and tender. A sa
aor
a wheal of 5 mm in diamele
 The vaccine must not be contaminated with
TUBERCULOSIS 227
onts oteraent. If alcohol is used to
swab
an antiseptic Studies have shown that the range of protection offered by
llowed to evaporate before the vaccine the skin, it must be
is given. BCGvaried from 0 to 80 per cent in different parts of the world.
6) AGE: The national vaccination The full explanation for the varying degrees of protection has
nuntry to country (41). In countries policies differ fromn yet to be found (52, 53). One suggestion for which there is an
where tuberculosis increasing epidemiological support, is that prior exposure to
Arevalent and the risk of
childhood infection is high (as is Some non-tuberculous environmental mycobacteria e.9.
the national policy is to administer
ancu either at birth (for
in
BCG very early in M. vaccae, M. non-chromogenicum) may have conferred
institutional deliveries) or partial immunity on the population and thus masked the
eeks of age simultaneously with other at
ce immunizing agents potential benefit of BCG vaccination (54). There is also
ciIch as DPT and polio. BCG
eana administered early
high level of protection, particularly against in life provides
evidence that exposure to other species (e.g., M. kansasi,
with the severe forms M. Scrofulaceus) have an antagonistic action against BCG (55).
of childhood tuberculosis and
tuberculous meningitis. This may be one reason why BCG was not found to be
and protective in the South Indian trial (45). However, infants and
risk. In countries with a low prevalence of
tuberculosis, young children, BCG-vaccinated before they had contact with
teriad
perhaps there is a diminishing need for widespread BCG
vaccination. In this sifuation, it would seem environmental mycobacteria, derived protection.
an reasonable to
restrict BCG vaccination to high risk groups, for There is a large body of evidence which supports the
Used example,
hospital personnel and tuberculin-negative contacts conclusion that BCG gives an appreciable degree of
gina known cases of tuberculosis particularly of
multi-drug resistant protection against childhood tuberculosis (55). The WHO,
S
TB (MDR-TB) (40, 44). on the basis of an extended review of BCG including the
Dries,
South Indian trial (56) holds that it would seem
ades. (7) PHENOMENA AFTER VACCINATION Two to
three unreasonable to stop current BCG vaccination programmes
n for weeks after a correct intradermal injection of a potent vaccine, (53) and recommends that the use of BCG should be
the a papule develops at the site of vaccination. It increases slowly continued as an antituberculosis measure (56).
in size and reaches a diameter of about 4 to 8
gthe mm in about (10) REVACCINATION The duration of protection
5 weeks. It then subsides or breaks intoa shallow ulcer, rarely
CCine

f the open, but usually seen covered with a crust. Healing occurs a
conferred by BCG is matter of dispute. Even 90 years after
fhe development of the vaccine, it is not known whether
re tor spontaneously within 6 to 1Z weeks leaving a permanent, tiny, booster doses are indicated or advisable. In fact, BCG
round scar, typically 4-8 mm in diameter. This is a normal
revaccination has not been included in the official
BCG
reaction (45). However, with overdosage, the local lesion and immunization schedule in India under the expanded
the later scar may be considerably larger and of irregular size. programme on immunization.
dried
Normally the individual becomes Mantoux-positive after a
ation (11) CONTRAINDICATIONS Unless specifically
period of 8 weeks has elapsed, but sometimes about 14 weeks
lities. indicated, BCG should not be given to patients suffering from
are needed. generalized
1orm. eczema, infective dermatosis,
8) COMPLICATIONS : BCG has been associated with hypogammaglobulinaemia, to those with a history of
bient
i kept
adverse reactions which include prolonged severe deficient immunity (symptomatic HIV infection, known or
ulceration at the site of vaccination, suppurative Suspected congenital immunodeficiency, leukaemia.
ment

(40)
lymphadenitis, osteomyelitis, disseminated BCG infection lymphoma or generalized malignant diseases), patients under
and death. Ulceration and lymphadenitis occurs in immunosuppressive treatment (corticosteroids. alkylating
light 1-10 per cent of vaccinations, and disseminated infection agents, antimetabolites, radiation), and in pregnancy. The
black OcCurs in less than one per million vaccinations. The effect of BCG may be exaggerated in these patients.
I
as a disseminated infection is usually associated with severe (12) DIRECT BCG VACCINATION Direct BCG
may abnormalities of cellular immunity. The risk of adverse vaccination, i.e., vaccination without a prior tuberculin test.
2d up reactions is related to the BCG strain used by different has been adopted as a national policy in many developing
rdea. manufacturers, the dose, the age of the child, the method of countries, including India. It permits a more rapid and
gth is immunization and the skill of the vaccinator (46). complete coverage of the eligible population, while reducing
aged there is a local abscess formation, it should be treated
lf the cost. No adverse effects have been reported even if BCG
by is given to tuberculin-positive reactors (45). However. it is
aspiration, in case it does not clear spontaneously. If this
is not successful, it sound practice to administer BCG during infancy before the
h tul should be incised and treated with local child has had contact with environmental mycobacteria, than
eeper applications daily with PAS or INH powder. There is no need
arged for systemic treatment with INH. The patient should be to resort to direct BCG at a later date, when the benefits of
BCG are doubtful as shown by the South Indian trial (57).
assured of the harmless nature of the lesion (47). In order to
avoid these complications, the vaccination should be strictly (13) IMPACT: BCG vaccination is less effective in
edure
intradermal and no other injection should be given for controlling tuberculosisas compared to active case-finding
maly
at least 6 months into the arm which received BCG and chemotherapy, as BCG offers only partial protection. In
itea vaccine (48). 1982, a WHO Expert Committee (58) concluded that
nge although BCG vaccination of uninfected individuals (usually
y 9) PROTECTIVE VALUE: The duration of protection is children) can preventtuberculosis in them, it can have only
1ques om 15 to 20 years. The local BCG infection generates an a relatively small epidemiological effect in that it will not
immunity response, which is associated with the contribute significantiy to the reduction in the overall risk of
Ecied evelopment
poss of, tuberculin hypersensitivity and withtrial it, infection in the community as a whole.
The first prospective control
ess3 Some immunity. (14) BCG VACCINATION AND HIV INFECTION
5C6 showed it to be years 80 per cent effective over an
ldbe Servation period of 20 (49). Since then several Following a review of relevant data, the Global Advisory
in Committee on Vaccine Safety (GACVS) has revised its
cen planned, controlled trials have been conducted "Tuberculosis previous recommendations concerning BCG vaccination of
Pro Parts of the world, including the children infected with HIV.
Frevention Trial" in South India (50, 51).
28 EPIDEMIOLOGY OF COMMUNICABLE
DISEASES
WHO had previously recommended that in countries with
high burden of TB, a single dose of BCG vaccine should be
iven to all healthy infants as soon as possible after birth
inless the child presented with symptomatic HIV infection.
However, evidence shows that children who were Hlv
ntected, when vaccinated with BCG at birth, and who later
developed AIDS, were at an increased risk of developing
iisseminated BCG disease. Among these children, the
enefits of potentially preventing severe TB are out weighted
oy the risks associated with the use of BCG vaccine. GACVS,
therefore, advised WHO to change its recommendation such
that children who are known to be HIV-infected, even if
asymptomatic, should no longer be immunized with BCG
vaccine (59). However, population with high prevalence of
HIV also have the greatest burden of TB, and in such
populations, uninfected children will benefit from the use of
BCG vaccine. Furthermore, with the increasing range and
COverage of interventions to prevent vertical transmission
from mother to child including early diagonsis of maternal
-
HIV infections; management of sexually transmitted
infections; safe delivery practices; maternal and infant
preventive antiretroviral medicines or maternal antiretroviral
therapy; and safe infant feeding -
the majority of infants
born to HIV-infected mothers are not infected and would
also be expected to benefit from BCG vaccination (59).
Unfortunately, accurate diagnosis of HIV infection in the
first year of life relies upon direct demonstration of the HIV
virus, as maternal HIV antibody is passively transferred to
the infant in utero. Currently available assays that can be
used to diagnose HIV in the first year of life are expensive
and technically demanding in many countries with
generalized HIV epidemics. WHO recommends that these
tests are first performed at or around 6 weeks age, yet this is
often after BCG vaccination has already been given (60)
(15) COMBINED VACCINATION : BCG may be given at
the same time as oral polio vaccine. DPT vaccine may also
be given at the same time as BCG, but in different arm
without reducing the immune responses or increasing the
rate of complications (50). Mixed vaccines containing BCG
have not yet been introduced.
An increasing number of industrialized countries are
likely to reconsider their BCG vaccination policy during the
coming years. To change from general to selective BCG
vaccination, an efficient notification system must be in place
in addition to the following "low endemicity" criteria: (a) an
average annual notification rate of smear-positive
pulmonary TB cases below 5 per 100,000; or (b) an average
annual notification rate of tubercular meningitis in children
aged under five years, below per 10 million population
during the previous five years; or (c) an average annual risk
of tuberculosis infection below 0.1 per cent (60).
To sum up, BCG vaccination is a fundamental component
of a national tuberculosis programme. Despite the
contradictory evidence of controlled trials, there is evidence
that BCG plays a valuable role in preventing severe forms of
childhood tuberculosis, viz meningitis and miliary tuberculosis.
Today, BCG vaccination is part of WHO Expanded
Programme on lmmunization. The greatest need for BCG
vaccination today is undoubtedly in the developing countries
of the world where tuberculosis is still a major health problem.
LATENT TB INFECTION
Persons with latent tuberculosis infection are infected
with M. tuberculosis, but do not have TB disease. The only
sign of TB infection is a positive reaction to the tuberculin
skin test or 1GRA TB blood test. They are not infectious and
cannot spread TB infection to others. Overall, withou
treatment, about 5-10 per cent of infected persons u
develop TB disease at some time in their lives. About halfo
those people who develop TB will do so within the first two
years of infection. For persons whose immune systems are
weak, especially those with HIV infection, the risk of
developing TB disease is considerably higher than for
persons with normal immune systems. Of special concern
are persons infected by someone with extensively drua.
resistant TB (XDR TB) who later develop TB disease, theso
persons will have XDR TB, not regular TB disease.
A person with latent TB infection has a skin test or blood test
result indicating TB intection; has a normal chest X-ray and a
negative sputum test; has TB bacteria in the body that are alive.
but inactive; does not feel sick, cannot spread TB bacteria to
others; needs treatment for latent TB infection to prevent TB
disease. However, if infected by a person with MDRTB or XDR
TB, preventive treatment may not be an option (61).
Health care interventions
Currently, three major categories of health care
interventions are available for TB prevention
1. TB preventive treatment;
2. prevention of transmission of TB infection through
infection prevention and control; and
3. vaccination of children with BCG vaccine.
Latent tuberculosis treatment (62)
It is not recommended that everyone with latent TB
infection (LTBI) should have TB treatment. Rather it is
recommended that certain "target" groups should receive
treatment. The main "target" groups considered to be most
at risk for progressing from latent to active TB include
people in low TB burden countries:
who have had recent contact with an infectious patient:
with silicosis;
infected with both TB and HIV;
who have been or who are in prison;
a hign
who are immigrants to a low burden country from
burden country;
who are homeless;
who are an illicit drug user;
who have certain clinical conditions, or conditions w
compromise their immune system, such as people witn
diabetes, and people with chronic renal failure.
are
In high TB burden countries the populations that
most strongly recommended for the treatment of latentr
intection are people living with HIV, and children under-ie
who are household contacts of pulmonary TB cases.
Recommended regimens (62)
ded:
Currently the following three regimens are recomme
Isoniazid daily or twice weekly for nine months
Isoniazid plus rifapentine once weekly for 12 weesihis
Rifampicin (or rifabutin) daily for 4 months (VI
regimen dots must be used)
bf 3 or
The WHO also recommends two other regime
ths of
4months of isoniazid plus rifampicin daily, and six mod of
isoniazid daily. In 2019 the results were repoant
2 clinical trials looking specifically at side effects. An in the
problem limiting the treatment of latent TB intectioi was
oCcurrence of adverse events with isoniazid. Theretoeations
recommended that in patients without couont Optio
ritampicin is likely to be the safest TB infection treatme
 TUBERCULOSIS 229
one or
Rehabilitation auring the treatment. Some strains can be resistant to
recen vears, there has been a good deal of fresh more drugs.
In
on the
subject of rehabilitation, because of the
hinkschieved in treating patients on domiciliary lines Definitions
cases based
SUCCe ith their normal work and life. The
lease refer to page 207 for classification of
rtion of
patients who need rehabilitation and work on drug resistance.
nroportoored conditions is becoming less and less. The
(25)
undetthat
roups n eed rehabilitation are those who are chronically auses of drug-resistant tuberculosisprogrammatic
and are stil
till excreting tubercle bacilli. Some of those who Drug-resistant TB has microbial, clinical and
causes. From a microbiological perspective, the resistance
is
resection may require rehabilitation to suit their
resection
had lung inetfective
physical and
mental bilities. caused by a genetic mutation that makes a drug or poorly
against the mutant bacilli. An inadequate
Surveillance administered treatment regimen allows drug-resistant
mutants
infected with 15.
Gurveillance is an integral part of any effective TO become the dominant strain in a patient inadequate
herculosis programme. 1t snould be concerned with two able 5 summarizes the common causes of
tuberculos
distinct aspects: (a)
s ance of the tuberculosis situation, treatment. However it should be stressed that MDR-TB is man-
and poor
tar oxample, by measuring the annual infection rates" made phenomenon poor treatment, poor drugs
uhich will guide the epidemiologist and health administrator adherence lead to the development of MDR-TB.
htindicating whether the lB problem is static, increasing or In all countries and especíally those where the number of
darrpasing; (b) surveillance of control measures applied such cases of tuberculosis is rising rapidly because of the
as BCG vaccination
and chemotherapy association with HIV, the development of resistant strains of
tuberculosis is a serious concern. In 2016, about 0.60 million
Role of hospitals people worldwide, are estimated to be infected with strains
Inspite of effective domiciliary treatment services, there of drug resistant tuberculosis. An accurate picture of drug
a
willalways be some patients who will be needing resistance is not available because few countries have
hospitalization. The main indications for hospitalization are reliable drug resistance surveillance system (3).
a) emergencies such as massive haemoptysis and It is estimated that primary MDR-TB in India is around
spontaneous pneumothorax (b) surgical treatment 2.8 per cent. The drug resistance in re-treatment cases is
c) management of serious types of tuberculosis such as 12 (10-13) per cent. Although the level of MDR-TB in the
meningeal tuberculosis, and (d) certain social indications, country is low in relation to percentage and proportion, it
such as when there is no one to look after the patient at home. translates into large absolute numbers (64).
DRUG RESISTANCE XDR-TB has been reported in India by isolated studies
with non-representative and highly selected clinical samples.
All drugs used in the treatment of tuberculosis tend to The magnitude of the problem remains to be determined
produce resistant strains. The resistance may be of two
types: (a) PRIMARY OR PRE-TREATMENT RESISTANCE
due to the absence of laboratories capable of conducting
quality assured second line drug susceptibility test (10).
ltis the resistance shown by the bacteria in a patient, who has
not received the drug in question before. That this is not It has been observed that resistance to isoniazid alone
always due to infection of the individual with drug-resistant does not affect the results of treatment so much, if proper
Dacili, is well known. It is an accepted fact that when the bacilli regimens for treatment or retreatment are prescribed, but
are rapidly multiplying, resistant mutants appear irrespective simultaneous resistance to isoniazid and rifampicin limits
ofthe administrationof any particular drug. According to one severely the results of the treatment.
ypothesis, drug resistance is induced by transterence The most serious danger of MDR Tuberculosis is that it is
tirough what are called "episomes". Episomes are non- much more difficult to treat, even where second line drugs
chromosomal heritable genes which can pass from one are available. Treatment of MDR tuberculosis can take at
bacterialcellto another. If there is a direct contact between the least two years and the results are poor. Second line drugs
ning episomes, the episomes leave the resistant cell cost 30 times as much as drugs used in SCC treatment of
nvade susceptible cells (63). (b) SECONDARY OR non-resistant tuberculosis patients. Patients with MDR
HQUIREDRESISTANCE Here the bacteria were sensitive tuberculosis may need to be hospitalised and isolated which
arug at the start of the treatment but became resistant to adds to the cost of treatment, to prevent transmission of
the p
drug during the course of treatment with it. primary resistant strains to others. Careful precautions are
necessary to prevent transmission, especially to health
hasresIstance means that certain strains of tuberculosis
0acili workers caring for MDR tuberculosis patients (65).
are not killed by the anti-tuberculosis drugs given
TABLE 5
inadequate treatment
Causes of
Providersprogrammes Patients:
Drugs inadequate drug intake
dtequate regimens inadequate supply/quality
Poor adherence
Dsence of Non-availability of certain drugs (or poor DOT)
guidelies or
happropriate (stock-outs or delivery
disruptions)
guidelines Lack of intormation
on-compliance with guidelines Poor quality Non-availability of free drugs
equate training of health sta Poor storage conditions Social and economic barriers
o combination
monitoring of treatment Wrong dosages or Malabsorption
Contrognized or Substance abuse disorders
grammesfunded TB
230 EPIDEMIOLOGY OF COMMUNICABLE DISEASES
The emegence of XDR-TB and high case fatality rate in
patients with HIV infection was the subject of an emergency
consultations held in Johannesburg on 7-8 September, 2006.
The issues included strengthening treatment adherence to
achieve high levels of completion (2 85 per cent) for all TB
patients ensuring that second line drugs used to treat MDR-TB
and ADR-TB are strictly controlled and properly
used
according to WHO guidelines. The steps required to limit the
impact of MDR-TB and XDR-TB were identified and
incorporated into a 7-point plan of action (66)
In the short term, countries should:
1. develop national emergency response plans for MDR.
TB and XDR-TB and ensure that basic TB control
measure meet international standards for TB care
and are fully implemented;
2. conduct rapid surveys of MDR-TB and XDR-TB using
a standardized protocol to assess the geographical and
temporal distribution of XDR-TB in vulnerable
populations;
3. strengthen and expand national TB laboratory
capacity by addressing all aspects of laboratory
procedures and managment;
4. implement intection control precautions in health-care
facilities according to WHO guidelines, with special
emphasis on those facilities providing care for people
living with HIV/AIDS.
In the long term, countries should:
5. establish capacity for clinical and public health
managers to respond effectively to MDR-TB and
XDR-TB;
6. promote universal acces to antiretroviral therapy for
all TB patients through close collaboration with
treatment and care programmes tor people living with
HIV/AIDS;
7. support and increase funding for research into the
development of new anti-tuberculosis drugs and rapid
diagnostic tests for MDR-TB and XDR-TB,
Prevention of Drug Resistance Since incomplete,
inadequate and irregular treatment is the main cause of drug
resistance, this can be prevented by (a) treatment with two
or more drugs in combination (6) using drugs to which the
bacteria are sensitive,and (c) ensuring that the tre atment is
complete, adequate and regular.
Please refer to page 219 for details of guidelines about
management of MDR and XDR-TB.
Tuberculosis and comorbidities
Several medical conditions are risk factors for TB and
poor TB treatment outcomes. Similarly TB can complicate
course of some diseases. It is therefore important to identify
these comorbidities in people diagnosed with TB in order to
ensure early detection and improved outcome.
TUBERCULOSIS AND HIV
Worldwide the number of people infected with both HIV
and tuberculosis is rising. The HIV virus damages the body's
natural defences -the immune system- and accelerates the
speed at which tuberculosis progresses from a harmless
infection to life-threatening condition. The estimated 10 per
cent activation of dormant tuberculoSis infection over the life
span of an intected person, is increased to 10 per cent
activation in one year, if HIv infection is superimposed.
Tuberculosis is already the opportunistic infection that most
frequently kills HlV-positive people.
Even in HIV positive cases, tuberculosis can be curerd
diagnosed in time and ireated propery. ood TB contral
programme is the best thing that can be done to cure and
extend the lives of HV positive individuals. With correct T
treatment, the HIV positive person having tuberculosis canB
gain, on an average two additional years of life (67).
Epidemiological impact
HIV and tuberculosis interact in several ways (65):
Reactivation of latent infection People who are
infected with both tuberculosis and HlV, are 25-30 times
more likely to develop tuberculosis disease, than people
infected only with tuberculosis. his is because HIV stops
the immune system working efectively and tuberculosis
bacilli are able to multiply rapidly. In developing countries
HIV associated tubercular disease is very common
2. Primary infection: People with Hiv are at risk of being
newly infected, it they are exposed to tuberculosis because
their weakened immune system makes them more
vulnerable. New tubercular infection in people with HIV can
progress to active disease very quickly.
3. Recurring infection: People with HIV who have been
cured of tuberculosis infection may be more at risk of
developing tuberculosis again. However, it is not clear
whether this is because of reinfection or relapse.
4. In the community: There are more new cases of active
tuberculosis because more people intected with tuberculosis
develop active disease, and those newly infected become ill
faster. This means that there are more people in the community
who are infectious to others. Larger number of people with
active disease mean more people will die from tuberculosis
unless they are treated. The association of tuberculosis with
HIV means that people suffer additional discrimination.
Community education is needed to increase awareness that
tuberculosis is curable and, most important, that people are no
longer infectious after the first few weeks of treatment.
Diagnosis of tuberculosis in people with H
The salient features are as follows (23):
1. Emphasis on integrated TB and HIV services, eg., HI
Screening at RNTCP designated microscopy centre.
2. Focus on early detection and early care.
a. Early detection of TB in PLHIV (persons living wi
vAIDS): Early suspicion of TB-symptoms a
or
duration among PLHIV; use of an expanded cina
algorithm for TB screening that relies on presence
four clinical symptoms (current cough, weignt to
fever or night sweats) instead only cough,
identify patients with presumptive TB; strengd
intensified case finding at ART, Link ARI centn
gro
argeted intervention projects for high risk S and
specially injection drug users; female sex wonfeon
men having sex with men etc. and ofteringpI HV
CBNAAT among presumptive TB cases among SIStant
b.Early detection and care of HIV infected drug-resie
TB patients by strengthening HIV testing in presuid
DR-TB cases; ensure access to Cutu d
aru
nrompt
Susceptibility test for HIV infected TB patients, Pand
1inkage of HIV infected DR-TB cases to ART centres
prompt initiation of ART in HIV infected DK
and
C. Strengthen HIV/TB activities among childreu
pregnant women.
infection,
In most people in the early stages of HIv without
symptoms of tuberculosis are similar as in peopie

infection. In areas where
HIV many people have HIV
fection, tubercul programmes should continue to focus
inteontifving infectious sputum-smear-positive cases
on
through microscopy. iowever, diagnosis of tuberculosis in
individual patients using the standard diagnostic tools can be
more difficult if they have advanced HlV infection because:
(al HIV positive people with pulmonary tuberculosis may
have a higher frequency of negative sputum smears.
Confirming the diagnosis may require sputum culture.
(6) The tuberculin skin test often fails to work in people
ho are HIV positive because it relies on measuring the
response of a person's immune system. If the immune
Nstem has been damaged by HIV, it may not respond even
though the person is infected with tuberculosis. HIV positive
people with tuberculosis, theretore, have a higher frequency
of false negative tuberculin skin test results.
(c) Chest radiography may be less useful in people with
HIV because they have less cavitation. Cavities usually
develop because the immune response to the tubercular
bacilli leads to some destruction of lung tissue. In people with
HIV, who do not have a fully functioning immune system,
there is less tissue destruction and hence less lung cavitation.
(d) Cases of extra-pulmonary tuberculosis seem to be
more common in people who are co-infected
In short-screen for tuberculosis using sputum smear
microscopy, if the result is positive, start treatment; if the
result is negative, but it is suspected that the patient has
tuberculosis, sputum culture should be carried out where
feasible to contirm the diagnosis and give treatment to those
with positive culture results.
Treatment for HIV infected TB patients
Based on the clinical history and investigation reports ART
medical officer will categorize patients as rifampicin sensitive/
rifampicin sensitivity status not known/clinically diagnosed
TB case, prior history of taking anti-TB drugs (Cat 1/Cat II),
and initiate daily anti TB treatment in Fixed Dosage
Combination as per RNTCP guidelines at ART centre itself.
The treatment of HIV positive individual with MDR-TB is same
asfor HlV negative patients. However, treament is more
difficult and adverse events more common, hence rigorous
monitoring in this particular group of patients is required in
order to ensure adherence to treatment, early detection and
treatment of adverse events reduce "lost to follow-up" (23).
ART must be offered to all patients with HIV and TB and
HIV and MDR-TB,
irrespective of CD, cell count. Start anti-
tuberculosis treatment first and then start ART as soon as TB
reatment is tolerated (between 2 weeks and 2 months). In
ne absence of ART, TB treatment alone does not
Signiticantly increase the CD, cell count, nor does it
sIgniticantly decrease the HIV viral load. The use of Highly
Active Anti-Retroviral Therapy (HAART) in patients with TB
can lead to a
sustained reduction in the HIV viral load. It can
AInctate immunological reconstitution, and decrease
defining illness and mortality. This beneiit is seen
actossdifferent range of CD, counts.
n addition to TB treatment, all HIV-infected TB patients
be provided access to care and support for HIV disease,
ng co-trimoxazole preventive therapy to reduce
among PLHIV by preventing opportunistic intections.
Immun
reconstitution flammatory syndrome (IRIS):
casionally,
experien atients with HIV-related TB may
radioora emporary exacerbation of symptoms, signs of
nic manifestations of TB after beginning5
TUBERCULOSIS 231
HIV-infected
treatment. This paradoxical reaction occurs in
thought to be a result of
patients with active TB and is
administration
immune restitution due to the simultaneous
of antiretroviral and tuberculosis medication.
Symptoms and
Signs may include high fever, lymphadenopathy, expanding
intra-thoracic lesions and worsening of chest radiographic
be
findings. The diagnosis of paradoxical reaction should
other
made only after a thorough evaluation has excluded severe
aetiologies, particularly TB treatment failure. For
paradoxical reactions prednisone (1-2 mg/kg for 1-2 weeks,
then gradually decreasing doses) may be used (23).
Isoniazid preventive therapy for PLHIVs
Isoniazid preventive therapy (IPT) is one of the 3-l's
globally recommended for prevention of incident TB among
HIV infected individuals. It is the most effective bactericidal,
anti TB drug available currently. While it protects against
progression of latent TB infection to active disease
1.e reactivation, it also prevents TB reinfection in persons
who are exposed to open TB cases.
All children living with HIV who have completed treatment
for TB successfully should receive lNH for an additional six
months. These children who do not have poor weight gain,
fever or cough currently, are unlikely to have active TB.
Those who have above symptoms may have TB and should
be evaluated for TB and other conditions. If evaluation shows
no TB, such children should be offered IPT regardiess of their
age. Children living with HIV who are more than 12 months
of age and who are unlikely to have active TB on symptom-
based screening, and have no contact with a TB case should
receive six months of IPT (10 mg/kg/day) as part of aa
comprehensive package of HIV prevention and care services.
Providing IPT to people living with HIV does not increase
risk of developing NH resistant TB later. Therefore, concern
regarding development on INH resistance should not be a
barrier to providing IPT (23).
For details regarding HIV and TB co-activities please refer
to chapter 7 also.
TUBERCULOSIS AND DIABETES
Diabetes has been shown to be an independent risk factor
for tuberculosis in community based study from south India
and multiple studies globally. It is suggested that diabetes
accounts for 20 per cent of all tuberculosis and 10 per cent of
smear positive TB (23). People with weak immune system as
in diabetes are at higher risk of progressing from latent to
active tuberculosis. The risk is 2-3 times higher than people
without diabetes. A large proportion of people with diabetes
and TB are diagnosed very late.
It is suggested that all people with TB should be
screened
for diabetes and screening for TB in diabetes should be
considered, particularly in setting with high TB prevalence.
People with diabetes and TB have a high risk of death
during TB treatment and of TB relapse after treatemt. As
diabetes is complicated by presence of other infectious
diseases also, it is important to take proper care of diabetes
in patients suffering from diabetes/TB (68).
National framework for joint TB-diabetes collaborative
activities are as follows (23):
a. Activities to improve diagnosis and management
diabetes among TB patients:
of
screening of all registered TB patients for
diabetes
mellitus.
ensuring diabetes mellitus management among TB
patients.
 EPIDEMIOLOGY. OF COMMUNICABLE DISEASES

b. Activities to improve diagnosis and management of TB
amongdiabetic patients
Intensitied detection of active TB disease among
diabetic patients.
Ensuring TB infection control measures in health
care settings where diabetes mellitus is managed.
Ensuring TB treatment and management in comorbid
patients.
C. Joint monitoring and evaluation.
d. TB patients diagnosed with diabetes should receive the
same duration of TB treatment with daily regimen as
non-diabetic patients.
TB AND TOBACCO (23)
Tobacco smoke contains toxic chemicals which cause
disturbances in the bronchial surface of the lung. It also weakens
the immunity of the patient to fight with TB bacteria. The
following evidence emerges from several studies conducted to
look at the association of TB and tobacco in India:
Almost 38% of TB deaths are associated with the use of
tobacco.
Prevalence of TB is 3 times as high among ever-smokers
as compared to that of among never-smokers.
Mortality from TB is 3 to 4 times as high among ever-
smokers as compared to that among never-smokers.
Smoking contributes to half the male deaths in 25-69
age groups from TB in India.
Exposure to tobacco smoke has also been found to affect
TB in the following ways:
Increase the risk of tuberculous infection and the risk of
developing TB.
Affect clinical manifestations and increase risk of relapse
among TB patients.
Affect microbiological conversion (sputum smear or
culture) and outcome of treatment in TB patients
Increase tuberculosis mortality and drug resistance to
anti-tubercular drugs.
notifications fell by more than 50% between the end of March
and late April 2020, following the imposition of a national
lockdown. Subsequently, there has been some recovery, but a
of the end of June, not to pre-March levels. Decreases occurred
in both the public and private sector as shown in Fig. 6.
The impacts of COVID-19 on TB services and mitigation
strategies are as follows (1)
Impacts on health service availability
Fewer health facilities providing out-patient care for
people with drug-susceptible TB
Fewer health facilities providing out-patient care
for people with multidrug- or ritampicin-resistant
(MDR/RR) TB
Fewer hospitals providing in-patient care for people
with drug-susceptible TB
Fewer hospitals providing in-patient care for people
with MDR/RR-TB
Reduced number of out-patient visits for people with TB
People with TB asked to self-isolate at home
Reallocation of TB resources to the COVID-19 response
Reallocation of NTP staff at national or sub-national
level
Reallocation of funding
Reallocation of GeneXpert machines
Mitigation strategies to facilitate continued access to treatment
ProvidingTB patients with at least a 1-month supply
of anti-TB drugs
Home delivery of anti-TB drugs
Enabling TB patients to nominate a household
member to collect their drugs
Expanded remote advice and support using digital
technologies
50,000 Lockdown
Total

When a patient gets registered as a TB case, the status of

tobacco use is recorded in the TB treatment card. He/she is
advised to quit tobacco use with 5 R's Relevance of 40,000
quitting; Risk of continuing; Reward of quitting; Roadblock
to quitting; and Repeat at each visit.
TUBERCULOSIS AND COVID-19 (1) 30,000 Public sector
V
Since the beginning of2020, the COVID-19 pandemic has
caused enormous health, social and economic impacts,
which are likely to continue in 2021 and beyond. Even after
some of these impacts have been mitigated or contained, Z 20,000
there wilI be medium- and longer-term consequences,
including for the tuberculosis (TB) epidemic and response.
The pandemic threatens to reverse the progress made
towards globa 1TB targets. Although physical distancing
policies may help to reduce TB transmission, this effect could 10,000
Private sector
be offset by longer durations of infectiousness, increased
household exposure to TB intection, worsening treatment
outcomes and higher levels of poverty. In the absence of
effective mitigation strategies, such as social protection and
health insurance, severe economic contractions and loss of 2 3 45 67 8 9 1011 12 13 14 15 16 17 16 90
21 22 23 24 2520

income (particularly among the most vulnerable populations)

are likely to worsen some of the factors that determine TB Week, 2020
epidemics, especially the prevalence of undernutrition. FIG. 6
Trends in weekly TB case notifications in India in 2020.
INDIA ,
before and after lockdown
In India, the weekly and monthly number of TB case Source (1)
 TUBERCULOSIS 235
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 POLIOMYELITIS 243
during routine immunization services. The (VDPV) is being
receit d children poliovirus and Vaccine Derived Polio Virus
year old infants should receive all their is continuing at
includi 0-1 PPI doses. There is no minimum maintained. Environmental surveillance in 2012.
scheduled doses and d four sites with establishment of two new sites
PPI scheduled OPV doses (32). identified 107 high risk blocks
interval between Government of India has strategy is being
Dortant improvement in PPI during 1998 has been Tor polio where a multi-pronged
Ano
hygiene and clean
the
of vaccine vial monitor. Colour monitors or labels mplemented to ensure sanitation, each and every
vaccine bottles. Each label has a circle of deep arinking water in addition to vaccinating
are pu on
colour. Inside it is a white square which changes colour child oral polio vaccine (OPV
blue
gradually becomes blue, if vaccine bottle is exposed to
and temperature. When the colour of the white square
. Migratory population from UP and BiharGujarat and
are being
Identified in the states of Punjab, Haryana, are being
mesbe blue like that of surrounding circle, the vaccine West Bengal and these migratory children
Immunization LDay
ld considered ineitective. Thereby, the health worker cOvered during the Sub National
an easily ascertain that the vaccine being given is effective (SNID) in UP and Bihar.
not. This mechanism has been made mandatory in all 7. Social mobilization activities are being
intensitied by
religious
arcine procurements since 1998. This quality assurance involving the local influencers, community and and
will ensure that the children will have better protection leaders to improve community participation
against polio in 1999 and
thereafter. acceptance of polio vaccine.
8. A rolling emergency stock of oral polio
vaccine (OPV) is
Following recommendations from the India Expert wild polio vaccine
Advisory Group on Polio Eradication (IEAG), several being maintained to respond to any polio virus
(WPV) or circulating vaccine derived
strategies were utilized during 2005 and early 2006 to
imnrove the impact of SIAs: (i) development and licensure of (cVDPV) detection
has
monovalent OPVI (mOPVI) and mOPV3 for targeted use As part of the polio endgame strategic plan, India
(ii) deployment of programme
during SIAs based on surveillance data; introduced IVP in the national immunization switch was
additional peronnel to assist with intensified SIAs in the States from 30th November 2015 and tOPV bOPV
of Bihar and UP and in Mumbai City; (ii) social mobilization carried out in April 2016 (35).
targeted at reaching population groups missed during AFP SURVEILLANCE PPI is supported by AFP
previous SIAs; (iv) use of mobile teams to vaccinate children surveillance system since 1997. It is being conducted
through
at transit points (e.g. railway and bus stations) and on moving a network of surveillance medical officers (SMOs), who are
trains; and (v) increased engagement and accountability
of a defined area.
specially trained and are responsible for
political leaders and of health staff at all levels. To further A national surveillance team is positioned in
Delhi. The SMOs
improve population immunity in the most critical age
group, state headquarters and at regional places
are located at the
recommendation at its May 2006 system has
the IEAG added a specific in case of larger states. A regular weekly reporting
meeting identify and target all neonates in high-risk areas of of more meticulous search/
to been established. As a result
UP with a "birth dose" of mOPV1 (33). reporting, the number of reported cases of AFP increased
The last case of polio in the country was reported from from 1,005 in 1996 to 11,675 and the completeness of stool
on specimen collection improved markedly from 59
per cent in
Howrah of West Bengal with date of onset of disease (2).
13th January 2011. Thereafter no polio case has been 1998 to 82 per cent at the end of September 2020
reported in the country. On 27th March 2014, India
was
declared as non-endemic country for polio. References
WHO (2017), Weekly Epidemiological Record No. 15, 2018.
The steps taken by the Government to achieve the target
1.

state are as 2 WHO (2020), Weekly Epidemiological Record No. 38, 2020
of polio eradication and maintain the polio-free 3. WHO (2016), Weekly Epidemiological Record No. 36/37, 9th Sept.
follows(34) 2016.
states and union territories in the country have 4 WHO, Immunization, Vaccines and Biologicals, About the Polio
Allaeveloped a Rapid Response Team (RRT) to respond
to Endgame Strategic Plan.
IPV introduction,
country. An Emergency 5 EPI (2014), The Polio Eradication Endgame, Brief on
any polio outbreak in the OPV withdrawal and routine immunization strengthening,
March
has also been
reparedness and Response Plan (EPRP) be undertaken 2014.
developed by all states indicating steps to EPI (2015), Polio-Global Eradication InitiativePreparing for
6.
n case of detection of a polio case. withdrawal of all oral polio vaccine (OPV): Replacing trivalent OPV
child is being with bivalent OPVfrequently asked questions, Feb. 2015.
In thestates of UP and Bihar every new bornimmunization Today, Key Points about
polio 7. EPI, Polio-Global Eradication Initiative-Polio
dentified and vaccinated during the containment.
campaigns and is being tracked for 8
subsequent rounds. Biologicals, Fractional dose
the pulse 8. WHO (2016), Immunization, Vaccine and
3 n order to reach every eligible child during of vaccinatin9
IPV.
POllo round, apart from the strategy 9 WHO (2016), Weekly Epidemiological Record No. 34, 26th Aug. 2016.
to house visit, efforts 10. Global Polio Eradication Initiative, Data and Monitoring,
Surveillance
idren at fixed booths and house at railway stations, (2010), Weekly Epidemiological Record, No. 23, 4th June, 2010.
accinating children in transit stops, markeer
11. WHO
12. WHO (2012), Weekly Epidemiological
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e long distance trains, major bus No. 156-157 P58
road crossings etc. 13. Provoost, P (1985). Children in the Tropics
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Oughout the country have been bordering neighbouring 15. Christie, A.B. (1980). Infectious Diseases:
Epidemiology and Clinical
s are established in areasand Attari train station in Practice, 3rd ed, Churchill Livingstone.
D es like Wagah border in Barmer district
o 16. Jewetz, Melnick and Adelberg's. Medical
Microbiology, 26th Ed, 2013,

Dab and Munabo train station 5 years of age ALange Medical Book.
Raja
n, ensure that all children under
toacross 17. WHO (1983). Tech. Rep.
Ser.No.693
polio drops.
g from the border are given surveillance 18. ICMR (1975). ICMR Bulletin, Jan.
1975.
through R.et al (1983). Bull WHO, 61 (4) 689-692.
a remely high level of vigilance circulation or
19. Krishnan,
country for any importation or
sthe
 FHEPATITISSE
253
Chronic hepatitis B intection can be treated with drugs. infections (mostly asymptomatic but sometimes symptomatic
eatment can slow the progression of cirrhosis, reduce chronic
in the form of acute hepatitis) may evolve into
incidence ofliver cancer and improve long term survival. WHO may further evolve
infections (usually asymptomatic), which morbidity and
ocommendsthe use of oral treatments- tenofovir or entecavir, into sequelae (cirrhosis and HCC) that lead to
c these are the most potent drugs to suppress hepatitis B virus. mortality. As there can be more 20-30 years between
Thou Tarely lead to drug resistance as compared needs to
with other
drugs, are simple totake (1 pill a day), and have few side effects
infection and mortality, viral hepatitis surveillance the
capture these three phases to fully describe
co require only limited monitoring. prevalent
In most people, however, epidemiological situation. Estimations of current.
the treatment only Supresses the replication of the virus prevent
infections guide testing and treatment, which would
Therefore, people who start hepatitis B treatment must mortality from the
continue it for life. Treatment using interferon injections may future morbidity and mortality. Current
the past quantifies
sequelae of chronic infections acquired in
be considered in some people in certain high-income settings, of past
the baseline burden and evaluates the impact
as this may shorten treatment duration. But its use is less interventions. The three components of viral hepatitis
feasible in low-resource settings due to high cost and significant surveillance as shown in Table 3, may be implemented
by
adverse effects requiring careful monitoring (27). different acts of the public health system. Thus, the
in March 2015, WHO launched its first "Guidelines for the programme responsible for viral hepatitis needs to
prevention, care and treatment of persons living with chronic consolidate and triangulate sources of information from
hepatitis B infection The recommendations are (27): these different systems to describe the epidemiological
promote the use of simple, non-invasive diagnostic tests situation of HBV and HCV infection.
to assess the stage of liver disease and eligibility for
treatment Global Health Sector Strategy on Viral
prioritize treatment for those with most advanced liver Hepatitis 2016-2021 (28, 29)
disease and at greatest risk of mortality; and In May 2016, The World Health Assernbly adopted the
recommend the preferred use of the nucleos(t)ide first "Global Health Sector Strategy on Viral Hepatitis,
analogues with a high barrier to drug resistance 2016-2021". The strategy highlights the critical role of
(tenofovir and entecavir, and entecavir in children aged Universal Health Coverage and the targets of the strategy
between 2-11 years) for first and second-line treatment. are aligned with those of the Sustainable Development
These guidelines also recommend lifelong treatment in Goals. The strategy has a vision of eliminating viral hepatitis
those with cirrhosis; and regular monitoring for disease as a public health problem and this is encapsulated in the
progression, toxicity of drugs and early detection of liver global targets of reducing new cases of chronic HBV and
cancer (27). HCV infections by 90% and reducing deaths due to viral
hepatitis by 65% (from 1.4 million to less than 500,000) by
Surveillance (27A) 2030. It focuses on HBV and HCV and proposes to increase
Infections with HBV or HCV evolve in three phases. New the coverage of preventions and to scale up testing and

TABLE 3
Activities that contribute to surveillance for viral hepatitis

1. Surveillance for acute hepatitis 2. Surveillance for chronic, 3. Surveillance for sequelae
that reflects new infections prevalent hepatitis
Regular biomarker surveys Combination of data from death
Activities Syndromic surveillance in the certificates, and testing of
general population patients with cirrhosis and HCC
Event-based surveillance for HBV and HeV infection
Enhanced case reporting (with
in-vitro diagnosis and collection
of information on risk factors
Persons without acute symptoms Persons diagnosed with cirrhosis
Population Persons presenting with acute and HCC
hepatitis to health-care facilities tested during population surveys
under
Surveillance (discrete onset of symptoms)
Hepatitis programme in Vital registration
Usual Communicable disease Sentinel sites caring tor patients
coordination with the other
implementer surveillance actors implementing with cirrhosis and HCC
Communicable disease surveys Cancer registries
surveillance (if countrywide biomarker
Hepatitis programme
(if sentinel sites)
Chronic HBV and HCV Cases of cirrhosis or HCC
Case Presumptive case of acute infection Chronic HBV or HCV infection
definitions hepatitis Serological evidence of past or
to use Confirmed case of acute
present HCV intection
hepatitis (by type)
Estimate the prevalence Estimate mortality from HBV- or
Objective of Detect outbreaks of infections HCV-associated HCC
Describe trends in type-specific
thesurveillance Model incidence trends and cirrhosis
activity acute hepatitis and identify
risk factors
HCV: hepatitis C virus
hepatitis B virus; HCC: hepatocellular carcinoma,
Source (27A)
 DiSEASES
LPDEMIOLOOY OF COMMUNICAREE infectious blood. This can n OcCur
254 through exposure to contaminated bloo ood transfusi
Health Sector of
through: (a) receipt organ transplants; (b) injections given
treatment. The key interventions of the Global
strategy for Viral Hepatitis are blood products and syringes and needle-stick injurie ries
1. Three-dose hepatitis
B vaccine for with contaminated (c) injection ion drug use, and (d) bein
Prevention health-care settings;
Interventions infants C-infected mother.
2. Prevention of HBV
mother-to-child born to a hepatitis through sex with
a
hepatitis B birth may be transmitted
transmission using Hepatitis C of personal items
contaminated
dose or other approaches. infected person or sharing common. Hepatifis
3. Blood safety and injection
safety,
with infectious blood,
but these are less or h
breast milk, food or water,
including use of engineered devices. C is not spread through ar
persons who use kissing and sharing food
4. Harm reduction for casual contact such as hugging,
person.
drugs. drinks with an infected
HCV.
5. Diagnosis of HBV and
Treatment
6. Treatnment of HBV and HCv Incubation period
Interventions for hepatitis C is 2 weeks tn
WHO commissioned a mathematical
model, which The incubation period
eliminated as a public 6 months.
suggests that hepatitis B and C could be
to viral hepatitis reaches
health threat by 2030 if the response of Symptomns
targets for five core interventions
the service coverage indicators, Following initial infection, approximately
80 per cent of
prevention, testing and treatment. The standard people who are
in Table 4. people do not exhibit any symptoms. Those
2015 baseline and the targets are as shown may exhibit fever, fatigue, decreased
acutely symptomatic
dark urine, grey-
HEPATITIS C appetite, nausea, vomiting, abdominal pain,jaundice About
from coloured faeces, joint pain and
Hepatitis C is a contagious liver disease that results clear the
infection with the hepatitis C virus. It can range in severity 15-45 per cent of infected persons sponteneously
any treatment. The
months of infection without
trom a mild illness lasting a few weeks to a serious, lifelong virus within 6
develop chronic
illness. It is among the most common virus that infect the remaining 55-85 per cent of persons will
HCV infection. Of those with chronic HCV infection, the risk
liver and it has been shown to be a major cause
of
of cirrhosis liver
of is 15-30 per cent within 20 years (31).
parenterally transmitted hepatitis.
Every year, 3-4 million people are infected with the Diagnosis (32)
hepatitis C virus. About 110 million people are HCV
Diagnosis of acute infection is often missed because
a

anti-body positive and 71 million are chronically infected

and are at risk of developing liver cirrhosis and/or liver majority of infected people have no symptoms. Common
cancer. More than 3,99,000 people died from hepatitis C
-
methods of antibody detection cannot differentiate between
related liver diseases in 2016. It is estimated that about acute and chronic infection. The presence of antibodies
2.3 million people were co-infected with HCV and HIV (27). against the hepatitis C virus indicates that a person is or has
been infected. The hepatitis C virus recombinant
Transmission immunoblot assay (RIBA) and hepatitis C virus RNA testing

The hepatitis C virus is most commonly transmitted are used to confirm the diagnosis. Diagnosis of chronic
TABLE 44

Baseline 2020 2030

Level Areas Indicators target
2015 target
Service Prevention 1. Three-dose hepatitis B vaccine for infants 82% 90% 90%
coverage (coverage %)
2 Prevention of mother-to-child transmission of HBV: 38% 50% 90%
hepatitis B birth-dose vaccination or other
approaches (coverage %)
3a. Blood safety: donations screened with quality 89% 95% 100%
assurance (coverage %)
3b. Injection safety:; use of engineered devices 5% 90%
(coverage %)
50%
4. Harm reduction (sterile syringe/needle sets 20 200 300
distributed per person per year for PWID)
Testing and 5a. Diagnosis of HBV and HCV
freatment (coverage %) <5% 30% 90%
5b. Treatment of HBV and HCv
coverage %) <1% 5 million (HBV) 80% eligible
3 million (HCV) treated
Impact feading Incidence Incidence of chronic HBV and HCV infections
to elimination Mortality Mortality from chronic HBV and HCV infections 6-10 million -30% 90%
1.46 million -10% 65%
HBV: hepatitis B virus; HCV: hepatitis C virus; PWID: persons
who inject drugs
While the service coverage target is about output ladoption of reuse-prevention injection devices),
(provision of safe injections). the C.5 indicator focusses on outcome
Source: (27A)
 EPIDEMIOLOGY OF COMMUNICABLE DISEASEs
94
CONTROL MEASURES Global strategy for dengue prevention and
control 2012-2020 (14)
a global rose
Dengue is a global threat that requires strategu nrense
Mosquito control involving all possible partners. The global motes
The vectors of DF and DHF (e.g., A. aegypli) breed in and among multisectoral
co-ordination and collaboration approach
around houses and, in principle can be controlled by individual partners on integrated vector managemenf goals and
and conmunity action, using antiadult and antilarval sustained control measures at all levels. The are
measures. These measures are outlined in chapter 14. by at least 50 per cent by 020
a. to reduce dengue mortality
morbidity by at least 25 per centi
2. Vaccines (13) b. to reduce dengue by
CYD-TDV is a prophylactic, tetravalent, live attenuated
2020; and
of the disease by 2015
c. to estimate the true burden
iral vaccine developed by Sanofi Pasteur in December
2015. The vaccination schedule consists of 3 injections of
J.5 ml administered at 6-month intervals. The indication
References
rom the first licenses is for the prevention of dengue illness 1 WHO (1993), Monograph on DenguelDengue Haemorrhagic Fee
SEARO
Compiled by Prasert Thongchroen, Kegional Publication,
caused by dengue virus serotypes 1, 2, 3, and 4 in No.22.
ndividuals 9-45 vears or 9-60 years of age (depending on 2. WHO (2020), Fact Sheet, 23rd June, 2020.
the license), living in dengue endemic areas. The lower limit WHO (2011), Comprehensive Guidelines for Prevention and Cante
3
of the indication at 9 years of age was chosen due to a safety of Dengue and Dengue Haemorrhagic Fever, Revised and expander ded
concern in children aged 2-5 years identified in the Phase 3 edition, Regional office of SEAR.
clinical trials. 4. Govt. of India (2018), Annual Report 2017-2018, DGHS, Ministry of
Health and Family Welfare, New Delhi,
CYD-TDV is available in a single-dose vial or in a 5. Govt. India (2019), National Heaith Profile 2019, DGHS,
of Ministry
of
multidose (5-dose) vial. It is a freeze-dried product to be Health and Family Welfare, New Delhi.
reconstituted before injection with either a sterile solution of 6 Govt. of India (2008), Guidelines for Clinical Management of Denque
0.4% sodium chloride for the single-dose presentation or a Fever, Dengue Haemorrhagic Fever and Dengue Shock Syndrome
sterile solution of 0.9% sodium chloride for the 5-dose Ministry of Health and Family Welfare, New Delhi.
presentation. After reconstitution, the 0.5 ml dose is to be 7. WHO (2012), Weekly Epidemiological Record, No. 8,24th Feb. 2012
administered by the subcutaneous route. The diluent is 8. Jawetz, Melnick and Adelberg's Medical Microbiology. 24th
International Ed. (2007), A Lange Medical Publication.
provided as a pre-filled syringe for single dose presentation
Govt. of India (2006), National Vector Borne Disease Control
or in a vial for the multi-dose presentation.The CYDTDV Programme, Ministry of Health and Family Welfare, New Delhi. Internet
dengue vaccine contains no adjuvant or preservatives. The 10. WHO (2009), Dengue Guidelines for Diagnosis, Trectment
shelf life of CYD-TDV is 36 months when stored between Prevention and Control, New edition.
2°C and 8°C. After reconstitution with the solvent provided, 11. Govt. of India (2014), Operational Guidelines Nationai Programme for
the vaccine must be kept at between 2°C and 8°C and Prevention and Control of Dengue, Ministry of Health and Family
protected from light. In accordance with the WHO multi- Welfare, New Delhi.
dose vial policy, any reconstituted doses remaining at the 12. WHO (2012), Handbook for Clinical Management of Dengue.
end of session should be discarded within 6 hours of 13. WHO (2016), Weekly Epidemiological Record, No. 30 29th July
opening/reconstitution or at the end of a vaccination 2016
14. WHO (2012), Global Strategy for Dengue Prevention and Contrl
session, whichever comes first. 2012-2020.
The manufacturer stipulates that vacination is contra- 15. Govt. of India (2020), National Guidelines Dengue case management
indicated in: (1) individuals with a history of severe allergic during COVID-19 Pandemic, 2020, NVBDCP Ministry of Health and
Family Welfare, New Delhi.
reaction to any component of the dengue vaccine or after the
prior administration of the dengue vaccine or a vaccine
containing the same components; (2) individuals with MALARIA
congenital or acquired immune deticiency that impairs cell-
mediated immunity: (3) individuals with symptomatic HIV Malaria is a protozoal disease caused by infection with
infection or with asymptomatic isk
HIV infection when parasites of the genus Plasmodium and transmitted to man
accompanied by evidence of impaired immune function; by certain species of infected female Anopheline mosqult
4) pregnant or breastfeeding women; and that vaccination A typical attack comprises three distinct stages: cold stage
should be postponed in individuals with moderate to severe hot stage and sweating stage. The clinical features ot malad
ebrile or acute disease. vary from mild to severe, and complicated, according tO
ace
3. Other measures Species of parasite present, the patient's state of immuniy
the intensity of the infection and also the presene
Isolation of the patient under bed-nets during the first few Concomitant conditions such as malnutrition or one
days; individual protection against mosquitoes diseases, 2
The personal prophylactic measures are wearing of full
he tebrile paroxysms occur with detinite
intermittent periodicity repeating every third or fourth y Bec
sleeves shirts and full pants; use of mosquito repellent depending upon the species of the parasite
reams, liquids, coils, mats etc., use of bed-nets involved
for sleeping
nfants and young children during day time to prevent Problem statement Ait
mosquito bite. pre
WORLD
The environmental measurements are detection and It took almost 30 years lobal ma
elimination of mosquito breeding places, management of from the end of the o
oof tops, porticos and sunshades, proper Malaria Eradication Programme (in
covering of stored emerge as a public health 1969) for malartaand
water, observation of weekly dry day. priority in global heala00
development discourse. Although
data from 1969 to
 MALARIA 295
scarce, 1his period was characterized by a sense of failure young children in stable transmission areas who have
e andonment in the fight against malaria. During these not yet developed protective immunity
against the
and aba
ndreds ol millions of people were infected with most severe forms of the disease
3 deens ofof households
millions mostly in sub-Saharan Africa 2. hon-immune pregnant women as
malaria causes high
ns
died, millstruggled
lailed fo emerge out of poverty
th catastrophic health expenditures,
rates of rniscarriage and can lead maternai
to
areas
death
of high
3, semi-immune pregnarnt women in
as they of thousands of pregnant women died in miscarriage and
during transmission. Malaria can resuit
first artd second
delivery to malaria-relafed complications, and millions low birth weight. especialiy duríng
children were born with low birth-weight, potentially pregnancies
oin fo early death or lifelong disability. Millions of 4. semi-immune HIV-infected pregnant
women in stable
transmission areas. during ali pregnancies. Womea
who survived, struggled with learning as they dealt
childre
due to multiple episodes of with malaria infection of the placenta also
have
with frequent absenteeism
laria, chronic anaemia, seizures or cognitive impairment higher risk of passing HIV infection to their newborns:
consequences of iniection and severe disease. Huge blows . people with HIIAIDS:
were
dealt to the growth of already weak national 6. international travellers from non-endemic
areas
economies, and their attempts to buildviable health systems because they lack immunity.
were hampered by lost productivity and
high demand for T.immigrants and their children living in non-endemic
health care. areas and returning to their home countries to visit
ot
Against this background, the first 2 decades of the 21st friends and relatives are similarly at risk because
century represent a golden era in the history of malaria waning or absent immunity.
control. The world pulled together to fight malaria, Malaria affects mainiy poor. underserved and marginalized
delivering one of the biggest returns on investment in global populations in remote rural areas which are characterized by
health. The unprecedented scale-up of malaria interventions inadequate control measures and limited actess to heaith
over this period has led to considerable reduction in disease care. Higher malaria prevalence has been reported among
incidence and mortality. These efforts coincided with other ethnic and tribal groups living in remote forested and border
trends and changes that have had a positive impact on areas, as well as among mobile and migrant populations.
malaria, including a period of considerable economic growth The childhood deaths resuit mainly from cerebral malaria
and development, infrastructure and housing improvements, and anaemia. Fatality rates of i0-30 per cent have been
rapid urbanization, and general improvements in health reported among children reerred to hospital with severe
systems and population health. The indirect effect of these malaria. However, these rates are even higher in rural and
gains on the overall health of populations and economies is
remote areas where patients have restricted access to
substantial (2). adequate treatment. Malaria also contributes indirectiy to
Globally, there were an estimated 229 million malaria illness and deaths from respiratory infections, diarrhoeai
cases in 2019 in 87 malaria endemic countries.The disease and malnutrition. Deaths from malaria in countries
proportion of P vivax was about 3 per cent in 2019, down outside Sub-Saharan Africa occur principally in non-
from about 7 per cent in 2000. Malaria case incidence, i.e. immune people who become iníected with P falciparum.
cases per 1000 population at risk reduced from 80 in 20000 Underreporting of malaria cases and deaths remain a
to 57 in 2019 globally. India contributed to the largest major challenge. Drug-resistant parasites. poor treatment
absolute reduction in the South-East Asia Region from seeking behaviour and the presence of counterteit
about 20 million cases in 2000 to 5.6 million in 2019. The antimalarial drugs further hinder control efforts. Resistance oi
South-East Asia Region accounted for about 3 per cent oi P. falciparum to the 4-aminoquinolines and sultadoxine-
the global malaria cases. pyrimethamine is widespread in almost all countries of SEAR.
Globally, malaria deaths have reduced steadily over the
with varying levels of severity. Resistance to matloquine was
reported from Myanmar and Thailand. Quinine has reduced
period 2000-2019, from 7,36,000 in 2000 to 4,09,000 in
susceptibility in Thailand. With progress irom mono-to-
4U9The mortality rate, i.e. deaths per lakh population at multidrug resistance, all malaria-endemic countries that have
SK, reduced from about 25 in 2000 to 10 in 2019. The falciparum malaria adopted thehighly ettective artemisinin
percentage total malaria deaths among children aged
of based combination therapy (ACT).
under 5 years was 84 per cent in year 2000, and 67 per cent
The coverage of indoor residual spraying with insecticides
per n
207
h South-East Asia Region, malaria deaths reduced (IRS) remains low (42 per cent). lnsecticide-treated nets have
cent, from 35,000 in 2000 to 9,000 in 2019. India
Ccounted for about 86 per cent of all malaria deaths in the
been introduced in almost all countries to supplement IRS
efforts, but the coverage remains extremely low
onGlobally, an estimated 1.5 billion malaria cases and
On malaria deaths have been averted in the period INDIA
U19, Most of the cases (82%) and deaths (94%)
Malaria continues to pose a najor public healt-
Re ere in African Region, followed by South-East Asia threat in India, patticularly due to Plasmodium
egion (10% cases
and 3% deaths). falciparum which is prone to comptications. In India abou
Alte in 33 moderate to high transmission countries in 21.98 per cent population iives in malaria high transmissior
nRegion, there were an estimated 33 million (1 case/1000 population) ateas and about 67 per cent ie
ancles, of which 35 per cent (12 million) were exposea low transnmission (0-l case/1000 population) areas (3;
alaria
malaria infection during pregnancy. It is estimated that About 91 per cent of malaria cases and 99 per cent of death
infection during regnancy in these 33 countries due to malaria is reported trom North-eastern states
Sulledin
8,22,000 children with low birth-weight (2). Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Andhr
The specificrisk groups following Pradesh, Maharashtra, Gujarat, Rajasthan, West Bengal an
Population1) for malaria includes the
Karnataka. However, the other states are also vulnerabl
 JAPANESE ENCEPHALITIS 327
375 million population is at risk. JE is mosquitoes
dia about
Ina most important vector in South India (7). These
In under the umbrella of Acute Encephalitis fields, shallow ditches and
reporte generally breed in irrigated rice
Syndrome (AES), therefore, the data reported from states pools. The rice fields are probably the
most important
are for
total AES5 iincluding JE cases. During 2016, 11,651 breeding places. These mosquitoes are zoophilic, teedin9
ES cases with
,301 deaths were reported. This includes
1,3 get intected
primarily on vertebrate hosts. Female mosquitoes
cases and 283 deaths. In 2017, 13,672 AES cases and after 9-12 days
1.676 JE
deaths includit 2,180 JE cases and 254 deaths aiter feeding on a viraemic host, to other hosts.
and 097 Incubation period, they can transmit the virus
a been reported. In year 2018, 11,382 cases with
687deaths were reported duue fo AES with 1,674 cases and JE IN MAN
182 deaths due to JE (5. The state-wise reported cases of
The incubation period in man, following mosquito bite
is
JE are as shown in
Table 2.
not exactly known. Probably, it varies from 5-15 days. Not
TABLE 2 all individuals bitten by infected mosquitoes develop
State-wise reported cases and deaths due to disease. The ratio of overt disease to inapparent infection is
JE in India 2016-2018 about 1:250. Thus cases of encephalitis represent only the
tip of the iceberg compared to the large number of
inapparent infections. Encephalitis cases due to JE may
2016 2017 2018 (P))
State Cases Deaths Cases Deaths Cases Deaths show a scattered distribution.
The course of the disease in man may be divided into
Assam 427 92 604 94 509 94 three stages: (a) PRODROMAL STAGE : The onset of illness
Bihar 100 25 74 11 70 11 is usually acute and is heralded by fever, headache
e Jharkhand 47 29 66 gastrointestinal disturbances, lethargy and malaise.The
Karnataka 26 2 35 duration of this stage is usually 1-6 days. (b) ACUTE
Manipur 47 186
1 10 57 3 ENCEPHALITIC STAGE : Fever is usually high, 38 to
Meghalya 47 448 4 90 6 40.7 deg. C. The prominent features are fever, nuchal
Odisha 242 42 79 143 0 rigidity, focal CNS signs, convulsions signs of raised intra-
Tamil Nadu 51 127 2 147 0 cranial pressure, difficulty of speech. dystonia. ocular
VSIT.a}
Tripura 98 90 59 palsies, hemiplegia, quadriplegia, extra-pyramidal signs like
01.
Uttar Pradesh 410 73 693 93 323 25 coarse tremors and altered sensorium progressing in many
West Bengal 174 39 165 40 140 35 cases to coma. (c) LATE STAGE AND SEQUELAE This
ASz
India Total 1,676 283 2,121 257 1,639 179
stage begins when active inflammation is at an end, i.e., the
temperature and ESR touch normal. Neurological signs
P-Provisional become stationary or tend to improve. Convalescence may
Source: (5)
be prolonged and residual neurological deficits may not be
uncommon (3). The case fatality rate varies between
Tra
Epidemiological features 20-40 per cent. The average period between the onset ot
illness and death is about 9 days (3).
pradi Unlike the dengue viruses, JE virus infects several
the es extrahuman hosts, e.g., animals and birds. Available Confirmation of a suspected case of JE requires
evidence indicates that the basic cycles of transmision are laboratory diagnosis. The aetiological diagnosis of JE is
mainly based on serology using lgM-capture ELISA which
(a)Pig Mosquito> Pig detects specific lgM in the cerebrospinal iluid or in the blood
10 (6) The Ardeid
bird Mosquito Ardeid bird of almost all patients within 7 days of onset of disease. Other
methods include conventional antibody assays on paired
The disease is transmitted to man by the bite of infected
sera for the demonstration of a significant rise in total
mosquitoes. Man is an incidental "dead-end" host. Man to JE-specific antibody, as well as a dot-blot lgM assay,
man transmission
Upera has not so far been recorded. suitable for use in the field. The virus is rarely recovered in
(a) Animal hosts: Among the animal hosts, pigs have tissue culture from blood or CSF, but may be found in
encephalitic brain at autopsy. JE-viral RNA is rarely
nncriminated
as the major vertebrate hosts for JE virus.
some places, upto 100 per demonstrated in the CSF (8).
cent of pigs may be intected
witn JE virus.
Infected pigs do not manifest any oveTE
ymptoms of illness but circulate the virus so thaat Control of JE
OSquitoes get infected and can transmit the virus to man. (a) VACCINATION: Vaccination of population
Cags are thus considered as "amplifiers" of the virus (6). been recommended. Currently, the three types at risk has
of JE
al and buffaloes may also be infected with the JE virus;
although they vaccines in large-scale use are : (i) the mouse brain-derived
may not be natural hosts of JE virus, they act purified and inactivated vaccine, which is
aniquito attractants." Horses are the only domestic the Nakayama or Beijing strains of thebased on eithe
s
to
OVinus
as pond
so far known which show signs of encephalitis due
infection. (b) Birds: Some species of birds sucn
produced in several Asian countries; (ii) the
derived, inactivated JE vaccine based on
JE virus
cell
ane
culture
the
herons; attle egrets and perhaps poultry and ducks strain, and (iii) the cell culture-derived, live Beijing P.
to be involved in the natural history of JE Virus (D) vaccine based on the SA 14-14-2 strain of the JE attenuate
Pear

MOSQUITO mouse-brain derived, inactivated virus. Th

VECTORS successfully to reduce the incidence
vaccine has been use
Culicine of JE in a numberr o

C. vishr mosquitoes, notably C.tritaeniorhynchus, countries, and is likely to be used

internationally for some more years. nationally an-
been inand C. gelidus along with some' anophelines have Drawbacks of t
Ctrit ninated as the veciors of JE. Among these, mouse-brain vaccine are the limited duration
nchus and vishnuihas been implicated as the protection, the need tor multiple doses, of the induce
and, in mo
 statement
LEISHMANIASIS 347
blem TABLE 2
1he epidemiological profile of VL and PKDL. cases In
ORLD endemic in many countries in tropical
SIS is

endemic states (India-2016))

hmaniaoaions. The 3 main forn
of the disease are
follows (3) Particulars Jharkhand West Bengal Uttar PradeshBihar

oishmaniasis (VL), also krnown as Kala-a VL PKDIL VL PKDL VL PKDL VL PKDL

isceral treated in over 95% of cases. It is Female 40% 43% 39.7% 40.8% 40% 50% 43% NA
proportion
fataorized by irregular Douts of fever, weight loss,
haractet of the spleen and liver, and <15 years
anaemia. Most (Child
35% 29% 25% 18% 37% 0 39% NA
enlareeur in Brazil, East Africa and in South-East Asia. proportion)
estimated 50,000 to 90,000 new cases of VL occur
casesated
each year. In 2018, more than 95% of new Source: (2)
wor
cases
rted to WHO occurred in T0 countries Brazil, :

tedia. Kenya, Somal

Ethiopia, Inald, henya,
Somalia, South Sudan, Sudan, Epidemiological determinants
Nepal.
China, Iraq and Agent factors
ous leishmaniasis (CL), Is the most common form
ihmaniasis and causes skin lesions, mainly ulcers, (a) AGENTS: The leishmania are intracellular parasites.
on exposed parts or tne oody, leaving life-long Scars and
They infect and divide within macrophages. At least
serious disability. About
95% of CL cases occur in the nineteen different leishmania parasites have been associated
Americas, the wediteranean dasin, the Middle
East and With human infection. Further, the majority of these offer no
Central Asia. In 2018 Over 85 per cent of new CL cases CrOSS immunity of one against the other (6). Leishmania
urred in 8 countries: Afghanistan, Algeria, Brazil, donovani is the causative agent of kala-azar (VL); L. tropica
OCcul
Colombia, lran (islamic hepuonc o, Pakistan, lunisia the causative agent of cutaneous leishmaniasis (oriental
15

Syrian Arab Republic. It is estimated that Sore); and, L. braziliensis is the causative agent of muco-
between600,000 to I milion new cases occur worldwide Cutaneous leishmaniasis. But this distinction is not absolute
annually
VISceral forms may produce cutaneous lesions, and
cutaneous forms may visceralize (7). The life cycle is
3 Muco-cutaneous lesihmaniasis leads to partial or total completed in two ditferent hostsa vertebrate and an
destruction of mucous membranes of the nose, mouth
andthroat. Over 90% of muco-cutaneous leishmaniasis insect; in the former, it occurs in an amastigote form (called
Casesoccur in Bolivia (the Plurinational State of) Brazil,
leishmania bodies") and in the latter as a flagellated
promastigote. (b) RESERVOIRS OF INFECTION: There is a
Ethiopla dna Feru. variety of animal reservoirs, e.g., dogs, jackals, foxes,
Kala-azar situation is worsening due the to occurrence of rodents and other mammals. Indian kala-azar is considered
ymptomatic cases, post-kala-azar dermal leishmaniasis to be a non-zoonotic infection with man as the sole
PKDL) undernutrition, and kala-azar/HIV Ccoinfection. reservoir. This assumption is based largely on the absence of
rate has decreased perhaps due to improved
Case fatality
evidence (8).
ase management in endemic countries.
Host factors
NDIA
(a) AGE: Kala-azar can occur in all age groups including
hala-azar is endemic in 54 districts in Bihar (33) infants below the age of one year. In India, the peak age is
ar khand (4), West Bengal (11) and Uttar Pradesh (6) 5 to 9 years (1). (b) SEX: Males are affected twice as often as
0U 130 million population is at risk of the disease. Ihe females. (c) POPULATION MOVEMENT: Movement of
ent ACL) and both cutaneous
situation is shown in Table 1. While population (migrants, labourers, tourists) between endemic
occur in India, and non-endemiC areas can result in the spread of infection.
and 1S far the most important leishmaniasis
visceral (VL) disease
(d) SoCIO-ECONOMIC STATUS: Kala-azar usually strikes
2T. by in
Kala-azar has notifiable disease
been declared as the poorest of the poor. Poverty increases the risk for kala-
nBthar and West
Bengal (5). azar. Poor housing and domestic sanitary conditions (e.g.
lack of waste management, open sewerage) may increase
TABLE 1
sandfly breeding and resting sites, as well as their access to
humans. Sandflies are attracted to crowded housing as these
Se Kala-azar cases and deaths in India (2016-2018 provide a good source of blood-meal. Human behaviour,
2016 2018 such as sleeping outside or on the ground, may increase risk.
State 2017 As a disease it more often debilitate than kills, and makes
(e) MALNUTRITION
Cases Deaths Cases Deains people become dependants on others;
Cases Deaths
A
Nest
4,773 4,127 3.4235 Diets lacking Protein-energy iron, vitamin and
Bengal
the risk that an intection will progress to kala-
UtarPradesh 177 156 95 zinc increases
107 110 0 azar (3). (G) OCCUPATTON The disease strongly associates
narkhand 115 0 with occupation. People who work in various farming
1,185 752 0 a great risk of
wdia
0 1,358 0 practices, forestry, mining and ishing have Recovery from
IMMUNITY
6,245 0 5,758 0 4,380 0 being bitten by sandflies. (g)
kala-azar and oriental sore gives a lasting immunity. During
SOurce:14)
is impairment of cell
the active phase of kala-azar, there in the negative skin
mediated immunity, this 1s reflected
ese 4 hmiological profile
of VL and PKDL cases in reaction to leishmanin
test.
Cstates are as shown in Table 2.
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES
In view of the changing trends in leprosy,
the Director
eneral of WHO placed the management of the
Leprosy Programme under the Regional Director, olo0a
Considering that this region has the highest sEA
burden or
aisease globally. The office and staff of the Global Leprosy
TOgramme moved from Geneva to New Delhi on
July 1st 2005. The WHO has evolved the Global Strategy
for further reducing the leprosy burden and sustaining
eprosy control activities 2010-2015, and more recenty
lobal Leprosy Strategy 2016-2020: "Accelerating towards
a leprosy-free world".
The Global leprosy strategy 2016-2020:
Accelerating towards a leprosy-free world"
The Global Leprosy Strategy 2016-2020: "Accelerating
towards a leprosy-free world" was released in April Z016.
Ine strategy is based on the principles of initiating action,
ensuring accountability and promoting inclusion. It is built
around 3 pillarS: to strengthen government ownership,
coordination and partnership; to stop leprosy and its
complications; and to stop discrimination and promote
inclusion. In endorsing the global strategy, 3 key targets
have been agreed by all national programmes (1 zero
grade 2 disability (G2D) among children diagnosed with
leprosy; (2) the reduction of new leprosy cases with G2D to
case per million population and (3) zero countries nude mouse. Despite repeated claims, M. leprae has no
with legislation allowing discrimination on the basis of
leprosy (3). Early detection and complete treatment with
MDT remains the fundamental principle of leprosy control.
INDIA
Leprosy is widely prevalent in India. Although the disease
is present throughout the country, the distribution is uneven.
After introduction of MDT in the country, the recorded
leprosy case load has come down from 57.6 cases per
10,000 population in 1981 to less than one case per
10,000 population at national level in December 2005, and
the country achieved the goal of leprosy elimination at
national level.
Based on the reports received from the states/UTs for the
year 2018-2019, the current leprosy situation in the country
is as follows (4)
A total of 1.203 lakh new cases were detected during the
year 2018-19, which gives annual new case detection rate
(ANCDR) of 8.69 per lakh population. A total of 85,302
cases were on record as on Ist April 2019, giving a
prevalence rate (PR) of O.67 per 10,000 population. The
detailed intormation on new leprosy cases detected during
2018-19 indicates the proportion of multibacillary cases was
52.28 per cent, proportion of female cases was 38.96 per
cent, child case proportion was 7.6 per cent (which gives
the child case rate of 0.87 per lakh population), 3.05 per
disability
cent patients were with grade-Il disability, giving
rate of 2.65 per million population).
already achieved the level of leprosy
34 states/UTs had
elimination i.e. PR of less than l case per 10,000
population. Chhattisgarh and Dadra & Nagar Haveli has
of 2-5 per 10,000 population.
of 708 have
As on 31st March 2019, 514 districts out
ANCDR less than 10 per lakh population, 72 districts have
population, and only 12 districts are
more than 20 per lakh 3 are in
population (of which
with more than 50 per lakh
Chhattisgarh, 1 in Gujarat, 2 in Maharashtra, in Dadra
1 &
Three districts reported
Nagar Haveli and 5 in Odisha.
ANCDR of more than 90 per lakh population.
Out of the total 1.159 lakh new
ases deleted
record, a total of 90,230 cases were
treatment during 2018.
edo
nde
Epidemiological determinants
Agent factors
(a) AGENT: LeproOsy is caused by M. lepra
acid-fast and occur in the human host botkThe
and extracellularly. Ihey ocCur characteristicall intraco ate
la
or bundles (called globi). They have an affinitu
cells and cells ot the retucuio-endothelial susto
cu
1o
n
remain dormant in various sites and cause
bacterial load is the nighest in the lepromatoie
.The The
many as 2 to Olnon were estimated in oses, As
leproma (5). Numerous antigens (more than 201
amof
detected in M. leprae by electrophoretic techniouos
of these are shared by those of pathogenic ome
pathogenie mycobacteria, e.g., BCG, M. on
M. vaccae, M. tuberculosis, etc. MOst interesting a
antigens is the phenolic glycolipid (PGL) which he
specific M. leprae antigen. Kecent years have witnocc lay
successful transmission ot M. leprae to some experimon
animals. Currentiy large quanuues OI M. leprae are be
produced by multiplication in the 9-banded armadillo
been conclusively shown to grow in artiticial medium (
is perhaps mainly for this reason that progress in rese
has lagged behind than that of many other diseases
(b) SOURCE OF INFECTION : It is generally agree
multibacillary cases (epromatous and bord
lepromatous cases) are tnemost important sour
intection in the community.The inapparent infectio
also source of infection. The role of individual
tuberculoid forms ot the disease as sources of infectio
clear. The current view is that all patients with
leprosy" must be considered infectious (7) Untl
man was considered to be the only host and so
infection. There is now evidence that natural intecti
M. leprae are present in wild animals, e.ga
mangabey monkeys and chimpanzees. It is notyet
leprosy in wild animals is a threat to public healthi
(c) PORTAL OF EXIT: It is widely accepted tha
is a major portal of exit. Lepromatous cases harbo
of M. leprae in their nasal mucosa which arece
when they sneeze or blow the nose. The bacilli
or broken skin of bacteriologica
through ulcerated
cases of leprosy (8).
(d) INFECTIVITY Leprosy is a highly intec
:
but of low pathogenicity (9). It is claimed that
patient can be rendered non-infectious by tre
dapsone for about 90 days (10) or with
3 weeks (12). Local application of ritampie
spray) might destroy all the bacilli within 8 day
(e) ATTACK RATES Among househoe
lepromatous cases, a varying proportIOn
o
12 per cent - is expected to show signs
PR
years (1l). This occurs despite treatmento
most, it not all, cases having been ine
periods, before treatment is sought.
Host factors
a) AGE : Infection can take place at an
upon the opportunities for exposure
generally rise to a peak between 20 and
 EPDENIOLOGY OF COMMUNICABLE DISEASLS

Some patients. Some leprologists preter specific CMI is effective in eliminat

the incubation period.

the te
period to incubation period because of the long durauo no of infection in the body, lesions healn/con
produces pauci-bacillary (PB) tupeontan
ontrokie

Knowledge of incubation period of relapses deficient; the disease spreads uncontrProsy

is Iso
as this will define the duration of surveillance multi bacillary(MBeprosy with nd
Ssental,
treatment has been
alter
involvement. Sometimes, the immun multn
stopped. onse
altered, either following treatment (MDTY
Pathogenesis of leprosy (12)
improvement ot immunological status, or
inflammation of skin or nerves and
Onset of leprosy is insidious. It affects nerves, skin and as Lepra reaction leading to tempor
othertissues
Tne eyes, it may also affect mucosa (mouth, nose, pharynX), disabilities/deformities.
testis, kidney, voluntary/smooth muscles, athogenesis ofPema
reticulo summarized in Fig. 1. leprosy
endothelial system and vascular endothelium.
Bacilli enter the body usually through respiratory system. Classification
t has low pathogenicity, only small proportion of Leprosy is a disease bedevilled by classife
a intected
people develop signs of the disease. Though intected, Madrid classification (18), Ridley-Jopling dn,e=
majority of the population do not develop the disease. After
entering the body, bacilli migrate towards the neural tissue
the Indian classification (20), etc. These
based on clinical, bacteriological, munological
an
and enter Schwann cells. Bacteria can also be found in histological status of patients.
macrophages, muscles cells and endothelial cells of blood The Indian and Madrid classification systemsar
vessels.
After entering Schwann cells or macrophages, fate of the
widely used in tield leprosy programmes:
essentially ditferent, as the following comparison she
ne
Dacterium depends on the resistance of the infected
individual towards the organism. Bacilli start multiplying Indian clasification Madrid clasification
slowly (about 12-14 days for one bacterium to divide into indeterminate type indeterminate
two) within the cells, get released from the destroyed cells tuberculoid type tuberculoid; Rat,
rais
and enter other unaffected cells. During this state, person borderline type borderline
remains free trom signs and symptoms of leprosy. lepromatous type lepromatous
As pure neuritic type
the bacilli multiply, bacterial load increases in the
body and infection is recognized by the immunological The Indian classification has an additional form, the
system. Lymphocytes and histiocytes (macrophages) invade neuritic in which no skin lesions exist.
the infected tissue. At this stage, clinical manifestation may The classification system of Ridley and Jopling
appear as involvement of nerves with impairment of divides leprosy cases into five groups according to
sensation and/or skin patch. If it is not diagnosed and position on an immuno-histological scale tuberculoid
treated in the early stages, further progress of the disease is borderline tuberculoid (BL), borderline (BB), bord
determined by the strength of the patient's immune lepromatous (BL) and lepromatous (LL The oeuri
response. of leprosy does not find a place in the Ridley and
Specific and effective cell mediated immunity (CMI) classification. This classification can be used only wa
provides protection to a person against leprosy. When research facilities are available.

M. Leprae

Enters Transient Bacillemia

Schwann cells, cooler places (cutaneous nerves &

peripheral nerve trunks of limbs and face)

Strong immunological Weak immunological

response
response

Nerves only: Pure neural leprosy M. Leprae multiply in Schwann celis

Escape fo skin: Skin lesions appear engulfed Histiocytes wandering macop
Lesions may heal spontaneously affects other organs of the g

FIG.1
Pathogenesis of leprosy
clinical classification for control programme LEPROSY 361
a diagnosis o1 leprosy,
After nnking oneshould group
d on certain characteristics.
without cap will be needed. Explain to the person what you
the care going to do
tient helps in selecting This is important and demonstrate it. Touch the skin with the
the corTect p ot the pen lightly
Use, combination of and ask the individual to point to the
rugs fora given patient. Spot touched with his index finger. Repeat this procedurea
ew times until the patient is familiar and comiortabie w
Crteria for classification (12) the procedure. Now ask the patient to close his eyes and
epeat the procedure (first on the normal skin then over the
Characteristics PB (Pauci-bacillary) attected area). While testing lesions over inaccessible areas
MB (Multi-bacillary)
Skin lesions 1-5 lesiopns Oack, buttocks) the patient may be asked to count on each
6 and above Ouch. Do not use other "instruments" like pin, cotton wool,
peripheral nerve No nerve / only one
More than one eather, etc. When testing for sensation, touch the SKin
nerve involvement
nerve involvement ghtly with the pen. Do not stroke. The pen should be
Skin smear Negative at all sites
Positive at any perpendicular to the surface of the skin. Do not keep asking
site
Diagnosis of leprosy (12) the patient whether he feels the touch. You may geet
misleading results. Proceed from the normal skin to
A Case of leprosy is diagnosed
patch. Give only one stimulus at a time. Vary the pace of
the
by eliciting cardinal
leprosy through Systematic clinical (and signs testing.
eauired bacteriological) wherever
examination. At least one of
llowing cardinal (unique ana
very important) the C. Nerve examination (12)
be present to diagnose leprosy.
signs must
Resource person should demonstrate nerve examinatioon
a
Hypo-pigmented or reddish skin from head to toe and also use
video clips. The cardinal SIg
lesion(s) with definite 1S: Involvement
sensory deficit: of the peripheral nerves, as demonstrated
. Involvement of the
by detinite thickening
with a loss of sensation with or
peripheral nerves, as demonstrated without weakness/paralysis of the corresponding
by definite thickening with loss of muscles ot
weakness /paralysis ot the sensation and the hands, feet or eyes".
Examination of nerves in all the
coTesponding muscles of the patients is very important for
hands, teet or eyes; diagnosis, grouping and toor
prevention of deformity. This involves two
Demonstration of M. leproe in the lesions. (a) palpation of the aspects
nerves for thickening. tenderness and
The first two cardinal signs can
be identified by clinical consistency; and (b) assessIment of nerve
and motor. The commonly affected nervesfunction sensory
-

examination alone, while

the third can be ídentified are as shown in
examination of the slit skin smear. by Fig. 2.

1.CLINICAL EXAMINATION Before the introduction of MDT,

most leprosy cases were
diagnosed by medical officer or specialized
Clinical examination and it often led to delay in leprosy workers,
includes careful interview of diagnosis and initiation ot
patient to get
detailed history and examination of the treatment. Since the introduction
skin and of MDT, marny procedures
nerves. have been simplified, so that
leprosy patients can be
delecied by health workers in the field.
a. Case history
The leprosy history
should elicitthe following:
Name, sex., age (year of Facial
birth), address, occupation
etc.;
Presenting complaints and
ew days or that which is their duration {A patch of a
present since birth or an itchy Median
patch is unlikely to
beleprosy):
History of recurrence (a
and goes" will not
recurrent lesion which "comes
be due to leprosy); Radial
Any detormity, the Ulnar
progress, time of its onset, and nature of its
Tre
reatment history treatment taken,
leprosy and how whal drugs 1or
long:
Any other associated illness
he feet at present
(jaundice, cough, swelling of
or in the recent past)
Any other person in the family
Similar disease
or close contacts having Lateral popliteal
or had the disease and was trealed. (common peroneal)
b. Physical
examination
thorough inspection of the body surface (skin) Posterior
to the
ent permissible, in good natural light for the presence
OSuggestive,
tibial
or tell tale evidence of leprosy
esting the sensation over
skin 2)
tis very nportant FIG.2
to pick up the skill of eliciting sensory Sites of nerve involvement
in patch. A light ballpoint pen (with plastic
body Source (21) :
70 PIDEMIOLOGY OF COMMUNICABIE DISEASESs

immediate contacts of a case of leprosy, especially Patients at high risk of developing disability
multibacillary, are known to have a higher risk ot develoDng People with the following features are more fit.
the discase than compared to the general population. It 1s develop lepra reaction and neuritis compared olhers Kely
important, ty
therefore, to consider possible interventions to thus subjected to developing disability - and
prevent the occurrence of leprosy among household contacts.
However, there mu Multi-bacillary leprosy
be robust trial evidence to demonstrate
that the drug/s used for chemoprophylaxis are safe, Past or present thickened/ paintui/tender nerve trun
eftective
and cost-efficient in terms of
the number of new cases Skin lesion on face
prevented. Adolescents, pregnancy, old age
On account of lack of consistent results from various Any inter-current infection
studies using various drugs (dapsone, acedapsone, Stages of involvement of nerve
ritampicin) it is too premature to advise chemoprophylaxiS as
a public health measure. Further research is needed to use Stage I
Stage oj nerve involvement NervesDecome
this as a routine tool to prevent the occurrence of disease swollen (thickened) due, to inflammatom
among contacts (41). response and tender, but no loss of function. Th
condition is reversible if action is taken early
VII. Disability Stage Stage of nerve damage Along with thickened
II: -

t
is estimated that approximately 25 per cent of the
patients who are not treated at an early stage of disease
develop anaesthesia and/or deformities of the hands and
feet. As a single disease entity, leprosy is one of the foremost
causes of deformities and crippling.
The deformities may result due to the disease process
(e.g. loss of eye brows, other facial detormities), or those
resulting from paralysis of some muslces due to damage to
peripheralnerve trunk e.g. claw-hand, foot-drop,
lagophthalmos), or those resulting from injuries or infections
to hands and feet (e.g scar contractures of fingers,
mutilation of hands and feet, corneal ulceration). Fig. 3
shows the process of disability in hands, feet and eyes.
Nerve damage
and painful peripheral nerves, associated with loss
of function (loss of autonomiC, sensory and motor
functions). This condition is reversible if suitable
action is taken early preierably within 6 months
Stage III: Stage of nerve destructionIn long standing
case of nerve involvement (usually more than
one year) nerve may become tibrosed, thin and
atrophic. Involved nerve is completely
destroyed and its function cannot be Tecovered
to any useful degree
There are two types of disabilities in leprosy:
1. Primary: These disabilities occur as a result of nerve
damage -
e.g. loss of sensation, paralysis,
dryness
2. Secondary: These occur as a result of neglected
primary disability e.g. ulcer, contrachure.
-

A disability is defined as lack of ability to perform an

activity.
Loss of sweat Loss Of sensation Loss of motor A deformity is a visible consequence of an impairment
unction inside the body.
The findings of the examination are first noted in the
Crack njury/pressure WeaknesS Disability Assessment Form separately for right and left eyes
hands and feet. Thereafter each eye, each hand and eacn
foot is given its own grade. Deformities are classified ino
three grades. The criterias are as follows (12, 42)
Ulcer Ulcer Contracture
Examination WHO Sensory Vountary
of parts Disability 1testing muscle testing
Grades
Process of deformity in eyes Sensation Muscle power
esent R normal
Nerve damage Hands Sensation Muscle power
absent normal
Sensation Muscle power
absent weak or paralyzed
Lagopthalmos Corneal anaesthesia Sensation Muscle power
present nor
Feet Muscle powe
Sensation
Exposure keratitis/ absent normal
Corneal ulcer
power
corneal ulcer Sensation Muscle
or paralyze
absent weak
Rlinkin
Binking
Blindness Blindness Vision Lid Gap Present
Normal No lid sap
Eye Cannot
appresentAbsen
FIG.3
COunt Ted ee
Process of deformity in hands, feet and eyes fingers at cornealuice
Source : (12) O metres or opacity
 COMMUNICABLE DISEASES
EPIDEMOLOGY OF
372 No. of new leprosy cases
detected in one year
4. EVALUATION ANCDR= Total population of
x100,000
control is to assess the
An important aspect of leprosy
on the endemicity Or the the area (as on 31st March)
impact ot the control operations
between different times ana Grade-2 disabilities
aisease, and to compare results for such an evaluation. It is (2) Rate of new cases with
places. Indicators are required
used and satisty per 10,00,000 population per year
important that these indicators can be easily they should
repeatability and validity. Ideally It is the rate at which new cases with disah
Definition:
the criteria of for action by
oe conceived and treated as signals grade 2 are detected in the denned geographical popula
ulation
two main types of
programme managers (6). There are area) in a given year.
indicators in leprosy control. Total no. of new cases
I. Epidemiological indicators RNCWG2D etCcted with Gr II disabilit
ityx 10,00,000
of the Total population of
lhese are required to evaluate the effectiveness
programme, that is to assess the impact of the action taken with the area (as on 31st March)
reduction. These indices are
regard to the problem (3) Treatment completion rate
(a) INCIDENCE Incidence rates are often calculated
:

sex,
separately for ditterent subgroups of population, e.g., age, Definition: It is the rate of patients who complete their
frequency of household contact. It is themost sensitive index of treatment on time as a proxy tor cure rate. Cohort analysis
transmission of the disease. It is the only index tor measuring of PB and MB cases are done separately.
the ettectiveness of the measures taken, 1.e., reduction o Number of new PB cases who
transmission. Thus they are useful in monitoring the success of completed MDT in 9 months
a control programme. (6) PREVALENCE
:
This provides a PBTCR x 100
measure of the "case load" and is useful in the planning of the Number of new PB cases who
treatment services. The continued reduction in the prevalence started MDT in a year
Could also give information about the downward trend of the Number ot new MB cases who
disease. It is often useful to calculate prevalence rates tor completed MDT in 18 months
different subgroups, e.g., age sex, geographic area. The tact MBTCR = X 100
that leprosy is not uniformly distributed should be borne in Number of new MB cases who
mind when these statistics are interpreted (6). started MDT in a year
A. Main or core indicators for monitoring 4. Prevalence rate (PR)
progress (41) Definition It is the total number of leprosy cases on
(1) The number and rate of new cases detected per record/under treatment per 10,000 population at a given
100,000 population per year. point of time in an area.
(2) Rate of new cases with grade-2 disabilities per Total number of leprosy cases on record x 10,000
100,000 population per year. PR =-
(3) Treatment completion/cure rate. Total population of the area
(4) Prevalence rate (as on 31st March)
(A case of leprosy is a person with clinical signs o
B. Additional epidemiological indicators (12) leprosy, who requires MDT)
Proportion of grade ll disabilities among new cases 5. Proportion of Grade II disability among new cases
Proportion of females among new cases (PG2DANC)
Proportion of MB among new cases
Proportion of child (0-14 years) among new cases Definition: It is the proportion (%) of new leprosy paten
with grade IlI disability among total new cases detected.
Child rate per 1,00,000 population
Scheduled caste new case detection rate No.
of Grade Il disabled cases
Scheduled tribe new case detection rate PG2DANC detected in a year X 10
lotal new cases detected in a year
C.Quality of service indicators (12)
Patient month blister calendar pack stock 6. Proportion
of female among new cases (PFANO
Absolute number otf patients made RFT Definition: It is the proportion (%) of new e
Number of relapse reported patients among total newly
detected cases.
Proportion of cases who developed new or additional
disability after starting MDI PFANC Number of new female patients X1
Proportion of treatment defaulters Total no. of newly detected cases
Proportion of new cases correctly diagnosed 7. Proportion of Multi-bacillary (MB) among neew case
(PMBANC)
Definitions
Andicators and formula to be used for their calculation
Definition: the proportion (%) of new patier
It is
indicated below: are diagnosed as MB among newly detected cases.
(1) Annual new case detection rate PMBANC Number of new MB cases
(ANCDR)
Definition Total no. of newly detected case
treated before) It
isthe rate at which new
cases 8. Proportion of child NC)
are detected in a detined geographical(never among new cases
a
block,district) in year (April-March) area Definition: proportion (%) of new leprosy pa ients u
14 years of age among
newly detected patients.
 L.EPROSY 373
Mission)
(now Leprosy
Mission to Lepers Himachal Pradesh
Number of child leprosy
cases detected 18/4 when the Baily at Chamba, in the moved to Purulld
100 tounded by
PCANTotal no. of newly detected leprosy
cases
X
as
The headquarters many
later
of this organizationvoluntary organizations
Bengal. Since then, use of leprosy.
up in the catNivaran Sangh
(CR) per 100,000 population west
now about 150) have sprung
Hind Kusht
Child rate : cases (0-14 yrs are the Association)
The rate ot new child leprosy mportant among theseEmpire Leprosy Reliet Wardha;
ition
among ne populanon of the area in a year. British Sevagram,
detected ormerly the Foundation,
age child cases (0-14 yrs) andhi Memorial
Leprosy the Damien
of
No. of new Leprosy Relief Association; and the more
detected in a year x 100,000 erman Save the Child Fund; A
roundation; the Danish taken over by the ICMR in 1975.
Population of the area was came into
CK
recent JALMA which Leprosy Organizationdiscuss their
(as on 31st March) body, "National to
Tederation platform
new cases detection rate provide a common
Scheduled caste (SC) Deing in 1965 to experiences. The campaign against
10.
new cases detected among problems and share theiraccomplished through an oflicial
Definition: lotal number of eprosy in India is Control Programme
in an area.
population in a given time programme, the National Leprosy n 1983, it was
the SC
Total number of SC cases the middle of 1954.
which was initiated in programme.
newly detected x 10,000 converted into an eradication Eradication
SCNCDR National Leprosy
Total SC population in an area An account of the
Programme is given in chapter 7.
new cases detection rate
11.Scheduled tribe (Sl) cases detected
Definition: Total number of
new ST References Record, No. 20, 18 May, 2001.
in given time in an area. 1.WHO(2001), Weekly Epidemiolgical Record, No. 28 14th July, 2000.
among the SI population Weekly Epidemiological
2. WHO (2000), 2020..
Total number of ST cases Record, No. 36, 4th Sep.,
3. WHO(2020), Weekly Epidemiological of Health and
newly detected - x 10,000 Govt. of India (2020), Annual
Report 2019-20, Ministry
STNCDK 4.
Total ST population in an Family Welfare, New Delhi.
a 5. Dharmendra (1985), Leprosy Vol lI, Samant
and Company, Bombay-
12. Patients month blister
calendar pack (BCP) stock 6. WHO (1988). Techn. Rep. Ser.,
No. 768.
and Management, Hind
(PMBCP) 7. Job, C.K. et al (1975). Leprosy: Diagnosis
to the Kusht Nivaran Sangh, New Delhi.
Definition : Stock of BCPs in months, according V. (1984). Ind. J. Lepr, 56, No.l (suppl).
in the nextt 8. Periaswamy,
number of patients expected to be treated 9. WHO (1980). A Guide to Leprosy Control.
quarter. 10. Last, J.M. ed (1980).
Maxcy-Rosenau : Public Health and Preventive
Number of blister packs of each Medicine, 11th ed., Appleton Century Crofts.
No. 1 (Suppl).
category PB(A/C), MB(A/C)]| 11. Prabhakar, M.C. et al (1984). Ind. J. Lepr, 56
PMBCP 12. NLEP (2019), Training Manual for Medical
Officers, 2019.
under treatment in each
No. of cases 63:231 245.
13. Van Braket, W.H. et al. (1992). Leprosy review,
-

category (PB(A/C), MB[A/C)]| Transmission of Leprosy, Internet.

14. WHO(2009),
15. Noordeen, S.K. (1980). In : A Manual of Leprosy. R.H. Thangaraj
13. Absolute number of patients made RFT
(ed
The Leprosy Mission, New Delhi.
Definition Number of patients released from treatment
:
16. Desikan, K.V. (1985). Ann. Natl. Acad. Med. Sci, India, 21 (4)207,
Th-
Curing the year. The number should include both the
new Jan. 1991.
Times of lIndia, New Delhi 30
and the other cases treated in a year. 17. Job, C.K. (1987). Ind. J. Lepr., 59 (1) 1-8.
18. International Leprosy Congress, Madrid (1953). lnt. J. Lepr., 21:504
14.Number of relapses reported
19. Ridley, D.S. and Jopling, W.H. (1966). Int. J. Lepr., 34, 255.
Dejinition: No. of relapse cases recorded in and 20. Chacko, C.J.G. (1980).In:A Manual of Leprosy. R.H.Thangaraj (ed
eported by) the PHC, District Hospitals, Medical colleges The Leprosy Mission, New Delhi.
and other institutions in the district during the given time 21. NLEP (2012). Disability Prevention & Medical Rehabilitatio
. Proportion of cases with new disability after
Guidelines for primary, secondary and tertiary levet care, June, 201
22. WHO (1998), Tech. Rep. Ser. No. 874.
starting MDT (PCWNDASMDT) 23. Yawalkar, S.. (1994). Leprosy for medical practitioners an
paramedical workers, Sixth Edition, CIBA-GEIGY Ltd.
Deinition: Proportion (%) of cases who developed new 24. Bryceson, A. and Roy. E.P (1979). Leprosy, 2nd ed.. Church
ine onal disability after starting MDT (new disability Livingstone.
es new nerve damage or new secondary impairment. 25. Van Brakel, W.H. et al. (1992). Leprosy review, 63:231-245.
26. Bharadwaj, V.P. (985). Ann. Natl. Acad. Med. Sci, 21 (3) 128.
No. of cases developed
27. Noussitou, FM. et al (1976). Leprosy in Children WHO.
new or additional disability
treatment 28. Ramu, G. et al (1980). Lepr India, 52 (3) 390.
PCWNDASMDT during x 100 29. Bharadwaj, V.P. et al (1981). Lepr India, 53:518.
No. of cases put under 30. Sinha, S. et al (1985). Ind. J. Lepr, 53:33-38.
MDT during the year 31. Dharmendra (1982). Lepr India, 54: 193.
6. Proportion of new cases correctly 13 32. Govt. of India (1982). Keport of the Working Group on the
aiagnosed (PNCCD) of Leprosy, Ministry ot fiealth and family Welfare, New Eradicatie
Delhi.
33. WHO (1982). Techn. Rep. Ser., No.675.
FNCCD No. of new cases correctly diagnosedx 100 34. WHO and NLEP India (2000), Guide to Eliminate
Leprosy as a Pub
No. of cases validated (DNT team Health Problem.
Anti-leprosy 35. Katochi, K. et al (1985). Ind. J. Lepr., 57 (3) 499.
TH activities in India 36. WHO (2003), The Final Push strategy to
Eliminate Leprosy as a Pub-
ory of anti-leprosy work in India goes back to Health Problem, Questions and Answers, 2nd Ed.
2003.
 linity treatment (TCT) 387
Total eammunity,
commu irrespective of
treatment of the
endemic the number of Europe and Central Asia, where the numbers of people
active
clinical cases; acquiring HIV infection and dying from HIV-related causes
Total targeted
treatment (TTT) treatment continue to increase. The global HIV epidemic during 2019
of
b. clinical cases and thei contacts (household,all active IS summarized
in Table 1.
playmates)
school,
WHO and UNAIDS has defined different types of Hiv
step in implemeting the new epidemics. They are as followws (3)
AS a first
As eradication
7 countries were
selected for the initial pilot Low-level HIV epidemics
stratctcampaigns.
Ireatment In 2012 it was implemented
in Betou
elle districts of Congo. In 2013, implementation was Although HIV may have existed for many, years. tt nas
and t
t in Ghana, Papua New Guinea and Vanuatu, Ever spread to substantial levels in any sub-population.
Recorded infection is largely confined to individuals with
achieving a coverage of more than 90 per cent. In 2014,
Cameroon, Indonesia, and Solomon Islands higher risk behaviour e.g. sex workers, drug injectors, men
are to naving sex with other men Numerical proxy
implement mass treatment activities (9), i
prevalence has not consistently exceeded 5% in any detined
Evaluation sub-population.
7.

Todetermine whether or not yaws has really been Concentrated HIV epidemics
ht under control, serological studies are needed. HIV has spread rapidly in a defined sub-population. but
ldeall if no yaws antibodies were tound among children
since the yaws mass campaign was completed, it would s not well-established in the general population. This
born
mean epidemic state suggests active networks of risk within the
that the campaign had been totally successful. The
actual sample of the population to be tested may be as low sub-population. The future course of the epidemic 1s
1 or 2 per cent.
determined by the frequency and nature of links between
as highly infected sub-populations and the general population.
Numerical proxy: HIV prevalence is consistently over 5%in
References at least one defined sub-population but is below 1% in
WHO(1981). Wkly. Epi. Rec., 56: 241-248.
pregnant women in urban areas.
WHO (1982). The Work of WHO, 1980-81.
2
WHO (1982). Techn. Rep. Ser, 674 Generalized HIV epidemics
4 (1980). Middle East Health, 4 (7) 33.
Wasley, G.D.
In generalized epidemics, HIV is firmly established in the
Chulay, J.D. (1979). Principles and Practice of Infectious Diseases,
Mandell, G.L. et al (eds), John Wiley, New York. general population. Although sub-populations at high risk
67. WHO (2016), Yaws Fact sheet, June 2016. may contribute disproportionately to the spread of HIV,
WHO (1968). The Second Ten Years of the WHO, 1958-1967 sexual networking in the general population is sufficient to
8. Hopkins, D.R. (1976). Am. J. Trop. Med & Hyg., 25:860. Sustain an epidemic independent of sub-populations at
9 WHO (2014), Fact Sheet, No. 316, Feb. 2, 2014. higher risk of infection. Numerical proxy HIV prevalence
consistently over 1% in pregnant women.
AIDS On the verge of fourth decade of the AIDS epidemic, the
world has turned the corner it has halted and begun to
AIDS, the acquired immuno-deficiency syndrome reverse the spread of HIV. The question remains how quickly
the response can chart a new course towards vision zero
sometimes called "slim disease") is a fatal illness caused by
a retrovirus known as the human immuno-deficiency virus
discrimination, zero new HIV infection and zero
AIDS-related deaths through universal access to effective
(HIV) which breaks down the body's immune system, HIV prevention, treatment, care and support.
leaving the victim vulnerable to a host of life-threatening
opportunistic infections, neurological disorders, or unusual HIV incidence (the number of new HIV infections in a
malignancies (1). Among the special features of HIV population per year) is the key parameter that prevention
infection are that once infected, it is probable that a person efforts aim to reduce, since newly intected persons
will be infected for life. Strictly speaking, the term
AIDDS contribute to the total number of persons living with HIV;
relers only to the last stage of the HIV infection. AIDS can be they will progress to disease and death over time; and are a
called our modern pandemic, affecting both industrialized potential source of further transmission. Since 1997, the
and developing countries. year in which annual new infections peaked to 3.2 million
cases globally, the number of new infections has fallen to 1.7
million in 2019. This reduction in HIV incidence reflects
Problem statement
natural trend of epidemic, as well as the result of prevention
WORLD programmes resulting in behavioural changes in different
early contexts, like changes in sexual behavior; programmes
ecognized as an emerging disease only in the targeting key populations such as harm-reducing
oUs, AlDS has rapidly established itself throughout the programmes for people who inject drugs; maximizing the
OTId, and is likely to endure and persist well into the
2lst
illness to a prevention benents ot Akvs, including for the prevention of
rg. has evolved from a mysterious
AlIDS mother-to-child transmission of HlV; and voluntary medical
has infected tens of millions people.
S0al pandemic which male circumcision in high HlV-prevalence settings (4).
recent years in
sing development have been seen in including Women represent about half of all people living with
ettorts to address the AIDS epidemic, HIV worldwide, and more than half (about 60 per cent) in
treatment and prevention sub-Saharan Africa. HIV is the leading cause of death
eased access to effective living witn
HIammes. However, the number of people deaths due to among women in reproductive age. Gender inequalities,
to grow, as does the number of differential access to services and sexual violence increase
AIDS des
particular trends affecting
concern are
Eastern
388 EPIDEMIOLOGY OF COMMUNICABILE DISEASES
1
TABLE
Global H1IV statistics (2019)

People living In 2019, there were 38.0 million (31.6 million-44.5 million) people living with
HIV.
with HIV 36.2 million (30.2 million-42.5 million) adults.
1.8 million (1.3 million-2.2 million) children (0-14 years).
81% (68-95%) of all people living with HIV knew their HIV status.
HIV.
About 7.1 million people did not know that they were living with
75.7 million (55.9 milion-100 million) people have become infected with HIV since the start of th
People living with As of the end of June 2020, 26.0 million (25.1 million-26.2 million) people were accessing antiretr
HIV accessing In 2019, 25.4 million (24.5 million-25.6 million) people were accessing antiretroviral therapy, up froma ther
antiretroviral (5.9 million-6.4 million) in 2009. m 6.4 mlli
therapy -In 2019, 67% (54-79%) of all people living with HIV were accessing treatment.
68% (54-80%) of adults aged 15 years and older liVing witn iv had access to treatment, as did 5e%136-6%
o
of children aged 0-14 years.
73% (60-86%) of female adults aged 15 years and older had access to treatment; however, just 61 (48-14%
la0
of male adults aged 15 years and older had access.
- 85% (63-100%) of pregnant women living with HIV had access to antiretroviral medicines to prevent hran.
of HIV to their child in 2019.
New HiV 2010, new HIV infections have declined by 23%, from 2.1 million (1. 6 million-2.9 million) to 1.7 mil
infections
Since
(1.2 million) in 2019.
million-2.2
Since 2010, new HIV infections among children have declined by 52%, from 3,10,000 (2,00,000-5.00.00
00.00)
in 2010 to 1,50,000 (94, 000-2,40,000) in 2019.
AlDS-related - AIDS-related deaths have been reduced by 60% since the peak in 2004.
deaths In 2019, around 6,90,000 (5,00,000-9,70,000) people died from AIDS-related illnesses worldwide, compared
1.7 million (1.2 million-2.4 million) people in 2004 and 1.1 million (8,30,000-1.6 million) people in 2010
- AIDS-related mortality has declined by 39% since 2010.
Women Women and girls accounted for about 48% of al new HIV infections in 2019. In sub-Saharan Africa, women and
girls accounted for 59% of all new HIV infections, five in six new infections among adolescents aged 15-19 years
are among girls. Young women aged 15-24 years are twice as likely to be living with HiV than men.
In some regions, women who have experienced physical or sexual intimate partner violence are 1. times more
likely to acquire HIV than women who have not experienced such violence.

90-90-90 - In 2019, 81% (68-95%) of people living with HIV knew their HIV status.
Among people who knew their status, 82% (66-97%) were accessing treatment.
And among people accessing treatment, 88% (71-100%) were virally suppressed.

Key populations Key populations and their sexual partners account for:
62% of new HIV infections globally
- 99% of new HIV infections in eastern Europe and central Asia.
-97% of new HIV intections in the Middle East and North Africa.
- 96% of new HIv infections in western and central Europe and North America.
-98% of new HIV infections in Asia and the Pacific.
t ri et
-.77% oft new Hlvintections in Latin America.
- 69% of new HIV infections in western and central Africa.
- 60% of new HIV infections in the Caribbean.
- 28% of new HIV infections in eastern and southern Africa.
The risk of acquiring HIV is :
- 26 times higher among gay men and other men who have sex with men.
- 29 times higher among people who inject drugs.
- 30 times higher for sex workers.
- 13 times higher for transgender people.
in three
HIV/tuberculosis TB remains the leading cause of death among people living with HIV, accounting for around one
AIDS-related deaths. approximately 95
(TB In 2018, an estimated 10.0 million (9.0 million-11.1 million) people developed 18 disease,
ped TB disease, appr
developins
whom were living with HIV.
. People living with HIV with no TB symptoms need TB preventative therapy, which lessens the isk of
TB and reduces TB/HIV death rates by around 40%. 018
. 1.8 million people living with HIV across 65 countries started preventive treatment for 15therefore nol
It is estimated that 44% of people living with HIV and TB are unaware of their coinfection and
receiving care

Source: (2) action

to
a beng bold call
vulnerability to HIV, and women, especiallu The UNAIDS 2016-2021 strategy is POple enda. IIs
women's more susceptible toto to get on the "Fast-Track" and reacn agenda
younger women, are DIologically untinis
behind. The strategy focuses on the
HIV (5).
a
call to reach the -90-90 treatment targets, to
call
-
AIDS 389
and to protect the health of the close the followed by Andhra Pradesh 3.14 lakh, Karnataka 2.69 lakh,
testingsle for 90 per cent people living with
of the Uttar Pradesh 1.61 lakh, Telangana 1.58 lakh etc. There
H
f their infection, 90 per centpeople with HIV being
of people aware were an estimated 69.22 thousand new cases in the country
have
he
HIV initiating ARI
and 90 per that in 2019. Maharashtra was estimated to have the highest
d ART
having undetectable levels cent of those number of new HIV infections (8.54 thousand), followed by
h 2020.
Milestone of HIV in their Bihar (8.04 thousand), Uttar Pradesh (6.72 thousand), West
bloonin new infectiontargets also include a 75 per
between 2010 cent Bengal (3.97 thousand) and Gujarat (3.37 thousand) cases.
ing annual HIV-related deaths to and 2020, and In 2019, there were 58.96 thousand AIDS related deaths
less than 500,000 by
2020 globally (6). in the country. Andhra Pradesh was estimated to have the
The Sustainable Development Goal target highest number of AIDS deaths (11.43 thousand) in 2019,
DS epidemic by 2030. UNAIDS has led is to end the tollowed by Maharasthra 9.69 thousand, Karnataka
the development 6.39 thousand, Telangana 4.08 thousand and Uttar Pradesh
fa global strategy, "tast Irack : Ending the AIDS 3.87 thousand (8).
2030, while more detailed, sectoral strategyEpidemic
heWHO sector strategy on HIV 2016-2021 such as
mder development. are Key population affected in India
The main areas of focus post-2015
nclude (4): The HIV epidemic in India is driven by sexual transmission,
A
which accounts for 86 per cent of new infections in 2017.
focus on population left behind by the HIV It is followed by parent-to-child, injecting drug users,
such as adolescent girls, key population (sex response, homosexuals and blood and blood products use etc.
men who have sex with men, people workers,
who inject drugs and According to HIV sentinel surveillance during 2016-
transgenderpeople), migrants and children;
2017, the overall HIV prevalence among ANC clinic
A focus on locations where
the greatest HIV transmission attendees (considered as proxy for prevalence among
isoccurring and with the greatest HIV burden, general population) continues to be low at 0.29 per cent,
use of data to support the impact of programmes;and the with an overall declining trend at national level. India
An integrated HIV response that expands continues to portray a concentrated epidemic. HIV
the prevalence among different risk groups is as shown in Fig. 1.
contribution towards universal health care, including
health workforce, procurement systems, injection Sex workers and HIV (FSW): In 2017, an estimated
and
blood safety, and treatment of coinfections; and 1.6 per cent of female sex workers in India were living with
Sustainable programmes with transitioning to domestic HIV, although this figure varies between states. For example,
fundingof essential HIV services. prevalence among FSW is estimated at 7.4 per cent in
Maharashtra and 6.3 per cent in Andhra Pradesh. Stigma
The interaction of HIV/AIDS with other infectious and discrimination against sex workers restrict their access to
iseases is an increasing public health concern. healthcare. NACO reported reaching 77.4 per cent of sex
uberculosis, bacterial infection and malaria have workers with HIV prevention activities in the year 2015.
been
dentified as the leading cause of HIV-related morbidity In the year 2017, around 67 per cent of HIV positive
in
üb-Saharan Africa. HIV infection increases the incidence sex workers were aware of their status and 91 per cent of
nd severity of clinical malaria in adults (7). sex workers (HIV positive and negative) reported using
The national HIV strategic plans in most SEAR countries condom (9).
ccord priority to prevention, care and treatment People who inject drugs and HIV :'Prevalence of HIV
nterventions to high-risk populations; however coverage of among injecting drug users (IDU) is high and major route of
comprehensive package of HIV interventions for sex HIV transmission in India's north-eastern states. In
2016,
orkers, men having sex with men, transgender persons and 1.7 million people in India were estimated to be injecting
jecting drug users remains low in all countries. drug users. In 2017, 6.3 per cent of people who inject drugs
were thought to be living with HIV, of whom half were
NDIA
2
aware of their status. Prevalence varies with states e.g.,
Now into its fourth decade, India's epidemic is marked by
eterogeneity-not asingle epidemic but made up ofa number ANC-0.28 A
distinct epidemics, in some places within the same state. MigrantS- 0.2 lt 2
The estimated adult (15-49 years) HIV prevalence trend
as been
declining in India since the epidemic's peak in the FSW- 1.6
2ar 2000 and has been stabilizing. The estimate the Truckers-h 0.2
ar 2019 was 0.22 per cent (0.24 per cent among adult
ales and 0.20 per cent for females). At the sub-national MSM 2.7
vel, three states with the highest adult HIV prevalence are
m the north-eastern part of the country, namely Mizoram TG- 3.1
per.cent, Nagaland 1.45 per cent, and Manipur IDU b.3
8 per cent. Other high adult prevalence rate states are
dhra Pradesh 0.69 per cent, Meghalaya 0.54 per cent, 2 4 6 10 12
iangana 0.49 per cent, Karnataka 0.47 per cent, HIV Prevalence (%)

.41 per cent, Maharashtra 0.36 per cent etc. lakh FIG. 1
tionally, there were an estimated 23.48 HIV prevalence for ANC attendees
and among
98 lakh-30.98 lakh) PLHIV in 2019, Maharashtra was different high risk groups, India, 2017
ated to have the highest number of PLHIV (8.96 lakh), Source: (9, 10)
396 EPIDEMIOLOGY OF COMMUNICABLE: DISEASES

1. Prevention hospitals and clinics. Pre-sterilized disposables

syring
needles should be used as tar as possible. One shom and
(a) EDUCATION injections unless they are absOlutely necessary, d void

Until a vacine or cure for AlDS is found, the only means

at present available is health education to enable people to 2. Antiretroviral treatment
make lite-saving choices (e.g., avoiding indiscriminate sex, At present there is no vacCine or cure for treatrma.
using condoms). There is, however, no guarantee that the HIV infection/AlDS. However, the developmonnent O

use of condoms will give full protection. One should also that suppress theHV intection itself rather thadgs
avoid the use of shared razors and toothbrushes. complications has been important development. TL
ntravenous drug users should be informed that the sharing antiviral chemotherapy have proved to be use
of needles and syringes involves special risk. Women prolonging the life of severely ill patients.
suftering from AIDS or who are at high risk of infection The availability ot agents in combination suppress H
should avoid becoming pregnant, since infection can be
transmitted to the unborn or newborn. Educational material
a
replication. It has prolound impact on the natural histo
of HIV infection. Patients wno achieve excellent suppressin
and guidelines for prevention should be made widely of HIV generally have stabil2ation or improvement of thei
available. All mass media channels should be involved in clinical course which results irom partial immunoloci
educating the people on AlDS, its nature, transmission and reconstitution and a subsequent decrease in complication
prevention; this includes international travellers. of immunosuppression. Concept about the timing.ofSuch
therapy have changed considerably.
(b) COMBINATION HIV PREVENTION (22)
Combination prevention programmes use a mix of Classification of drugs used for ART (18)
biomedical, behavioural and structural interventions to meet The drugs used for ART are classified as:
the current HIV prevention needs of particular individuals
and communities so as to have the greatest possible impact Nucleoside reverse transcriptase inhibitors (NRTIs)
on reducing new infections. Abacavir (ABC)
ARV drugs play a key role in HIV prevention. People Didanosine (ddl)
taking ART who achieve optimal viral suppression are Emtricitabine (FTC)
extremely unlikely to pass HIV to sexual partners. ARV drugs Lamivudine (31C),
taken by people without HIV as PrEP or PEP are highly Stavudine (d4l)
in preventing HIV acquisition.
Zidovudine (AZT)
ettective
Nucleotide reverse transcriptase inhibitors (NtRTs)
Other biomedical interventions that reduce HIV risk
Tenofovir (TDF)
practices and/or the probability of Hiv transmission per
contact event include the following: Non-nucleoside reverese transcriptase inhibitors (NNRTls)

Male and female condoms and condom compatible Efavirenz (EFV)

lubricant : male condoms are estimated to reducee Etravirine (ETV)
heterosexual transmission by at least 80% and to offer Nevirapine (NVP)
64% protection in anal sex among men who have sex with Protease inhibitors (Pls)
men, if used consistently and correctly. Fewer data are Atazanavir + ritonavir (ATV/r)
available for the efficacy of female condoms, but evidence Darunavir + ritonavir (DRV)r)
suggests they can have a similar prevention effect. ros-amprenavir + ritonavir (FPV/r) S
Needle and syringe programmes are highly associated with Indinavir + ritonavir (IDV/r)
a reduction in HIV transmission through injecting drug use. Lopinavir/ritonavir (LPV/)
Opioid substitution therapy with methadone or Saquinavir + ritonavir (SQV/r)
buprenorphine is the most effective form of treatment for Integrase strand transfer inhibitors (INSTIS)
opioid dependence and has the additional benefit of Raltegravir (RAL)
effectively reducing HIV risk behaviour and transmission Dolutegravir (DTG)
through injecting drug use. Opioid substitution therapy Fusion inhibitors
also provides adherence support to people on ART. Enfuvirtide (T-20, Fuzeon)
Voluntary medical male circumcision (VMMC): three
randomized clinical trials in Africa demonstrated an WHO recommended ARV treatment scheduleposed
approximately 60% reduction in the risk of female-to-
male sexual transmission. For high-burden settings, joint
HIV can be suppressed by treatment regimens
programme of WHO and United Nations on HIV/AIDS Oy a combination of 3 or more ARV drugs. Gurrent
(UNAIDS) recommended the inclusion of VMMC as an does not cure HIV infection, but highly suppr ls
replication within a person's body and allows an inaih
additional important strategy tor prevention of
heterosexually acquired HIV intection in men. immune system recovery to strengthen ga9016 WHO
capacity to fight off infections. Since20o
(c) PREVENTION OF BLOOD-BORNE
HIVv
recommended that all people living with HIVEbe Pa
TRANSMISSION with lifelong ART, including children ado ardles
adults, and pregnant and breast-feeding won
People in high-risk groups should be urged to refrain of clinical status or CD4 cell count.
from donating blood, body organs, Sperm
or other tissues.
current HIV treatment guidelines includer
fales
All blood should be screened for HIV 1 & HIV 2 before
ne nreviou
transfusion. Transmission of infection to haemophiliacs can options with better tolerability, higheretticacy
treatment of factors VIII of treatment discontinuation when compareanwnded th=

be reduced by introducing heat mmend

and IX. Strict sterilization practices should be ensured in recommended medicines. In 2019, WHO
 397
dolutegravir-base or low-dose efavirenz for first-line recommended as an
Ese of second-line therapy (23). EFV 400 mg is as an option for
everyone living with HIV including adults, EFV 600 mg maintained
therapy for alternative drug, with neonates and can
pregnant Women. women and adolescent girls of Special situations. RAL is recommended
for
solid formulations are
child-bearmg potential. children and people coinfected with be considered as an alternative
if LPV/r
chnTG should also be used in second-line therapy, if not less than 20 kg body
TB not available for children weighing recommended first-line
ed in firsi-line and darunavir/ritonavir is recommended as weight (24). Table 4 and 5 shows the
the anchor drug in third-line or as an alternative option and second-line ART regimens.
TABLE 4
Preferred and alternative first-line ART regimens
Population Preferred first-line regimen Alternative first-line regimen Special circumstances
- mg
Adults and adoescents TDF+3TC (or FTC) + DTG* TDF+3TC + EFV 400 mg TDF+3TC (or FTC) + EFV 600
AZT +3TC + EFV 600 mg"
TDF +3TC (or FTC) + PI/r"
TDF +3TC (or FTC) + RAL
FTC) + DTG
TAF+3TC (orDTG*
ABC +3TC +

Children ABC+3TC+ DTG4 ABC+3TC+LPV/r ABC+ 3TC+ EFV (or NVP)

ABC+3TC + RAL" AZT +3TC + EFVa (or NVP)
TAF +3TC (or FTC) + DTG AZT +3TC + LPV/r (or RAL)

AZT+3TC + RAL AZT+3TC + NVP AZT + 3TC + LPV/r

Neonates
STC:lamivudine;ABC: abacavir, AZT: zidovudine; DTG: dolutegravir, EFV: efavirene, FTC: emtricitabine; LPV/r: lopinavirhritonavir, NVP nevirapine,
Pir protease inhibitor boosted with ritonavir; RAL:women
raltegravir; TAF: tenofovir alafenamide; TDF: tenofovir disoproxil fumarate
Efective contraception should be offered to adult or
and adolescent girls of childbearing age potential.DTG
canbeprescribedforadu ooe
not otherwise using or accessing consistent and etfectivee
and adolescent giris or childbearing age or potential who wish to become pregnant or who are the end of the tirst
contraception if they have been tully informed of the potential increase in the risk of neural tube defects (at conception and until
trimester). If women identity pregnancy after the first trimester, DTG should be initiated or continued for the duration of the
pregnancy.
ART is preferred,
EFV-based ART should not be used in settings with national estimates of pretreatment resistance to EFV of 10% or higher. DTG-based
and if DTG is unavailable, a boosted Pl-based regimen should be used. The choice of PVr depends on programmatic characteristics.
TAF may be considered for people with established osteoporosis and/or impaired kidney function.
For age and weigh groups with approved DTG dosing.
should
RAL be used as an alternative regimen only if LPV/t solid formulations are not available
For age and weight groups with approved TAF dosing.
EFV should not be used for children younger than three years ofage.
Neonates starting ART with an RAL-based regimen should transition to an LPVr solid formulation as soon as possible.
LPV/r syrup or granules can be used if starting after two weeks of age.

TABLE 5
Preferred and alternative second-line ART regimens
Population Failing first-line regimen Preferred second-line regimen Alternative second-line regimens

TDF+3TC(or FTC) +DTG AZT +3TC+ ATV/r (or LPV/r) AZT+3TC + DRV/rd

Adults and TDF+3TC(or FTC) + EFV AZT +3TC+ DTG* AZT+3TC +ATV/r (or LPV/r or DRV/)4
adolescents (or NVP)
AZT +3TC + EFV (or NVP) TDF+3TC(or FTC) + DTG TDF +3TC (or FTC)+ ATV/r
(or LPV/r or DRV/Æ)d

ABC+3TC +DTG AZT+ 3TC + LPV/ (or ATV/) AZT +3TC +DRV/rs

ABC (or AZT) +3TC + LPV/r AZT (or ABC)+3TC + DTG AZT (orABC)+3TC +RAL
Children and infants
ABC (or AZT) + 3TC + EFV AZT (or ABC) +3TC + DTG AZT (or ABC) +3TC+ LPV/ (or ATV/)

AZT +3TC+NVP ABC+3TC + DTG* ABC+3TC+LPV/ (or ATV/ or DRV/9)|

DTG: dolutegravir; EFV: efavirenz:
3TC: lamivudine; ABC: abacavir; ATV/r: atazanavir/ritonavir; AZT: zidovudine; DRV/r: darunavir/ritonavir;
FIC: emtricitabine; LPV/r: lopinavir/ritonavir; NVP: nevirapine; RAL: raltegravir; TDF: tenofovir disoproxil fumarate.
Sequencing if Pls are used in first-line ART: ATV/r (or LPV/r. DRV/ depending on programmatic considerations)+ TDF + 3TC (or FTC) and then
AZT+3TC + DTG in second-line ART.
Efective contraceptionshouldbeoffered to adult women and adolescent girs of childbearing ageor potential.DTGcanbeprescribed for adult women
and adolescent girls of childbearing age or potential who wish to become pregnant or who are
not otherwise using or accessing consistent and effective
Contraception if they have been fully informed of the potential increase in the risk of neural tube detects (at conception and until the end of the first
or
trimester). If women identify pregnancy after the first trimester, DTG should be initiated continued for the duration the pregnancy.
of
(tenofovir can be used as an alternative NRTI in special situations for adults and adolescents.
AF alafenamide) adolescents.
AL+LPV/r can be used as an alternative second-line ART regimen for adulis and at
European currently only approves DiG tor children weighing least l5 kg and more widely for children weighing more than
he Medicines Agency
20kgwhocan take adult50mgfilm-coatedtablets. Studies are ongoing to determinedosingforyoungerchildren. with approval which was expected
n
in early 2020, but the 2016 WHO recommendations for second-line ART still hold (Plbased for childre for whom NNRTis have failed and RAL for
children for whom LPV/I has failed). TAF (tenofovir alafenamide) can be used as an alternative NRTI in children weighing at least 25 kg.
ATVIr can be used as an alternative to LPV/s children oider than three months. but the limited avalability ofsuitableformulations for children
for
youngerthansixyeat,thelack of afixed-dose formulation and the need for separate administration of the ritonavir booster should be considered when
Choosing this regimen.
should be combined with appropriate dosing of ritonavir.
DRV should not
be used for children younger than three years and
 EPIDEMIOLOGY OF COMMUNiCABLE DISEASES

programmes should plan carefully to ensure that who cannot tolerate or are contraindicate
DIGsupply available to meet the anticipated demand;a
is More than 1 million people living with HIvare NRTI
phased approach to implementation is recommended. using DTG in low and middle-inc currently
countries
everal countries have adopted approaches to start o are
and 7 show the transition ot people who stabloable 6
are stable
transitioning to DTG among people receiving first-line ART to a DTG-based regimen. on ART

TABLE 6
Considerations for transition to TDF + 3TC +DTG among adults and adolescents
Treatment transition scenario Preferred approach Comments
DTG for people living with HIV initiating ART
Adults and adolescents Initiate TDF + 3TC + DTG Potential risk of neural tube defects amonginfants
exposed to DTG during the conception period
Women not using or accessing contraception orwho
want to be pregnant can use DTG or EFV based on
informed choice of the risks and benetits of each regimen
Pregnant and breast-feedingwomen Initiate TDF +3TC +DTG Possibility of conception during breast-feedingremains
TB coinfection Initiate TDF +3TC + DTG DTG 50 mg twice daily if rifampicin is being
used as the
(DTG dose adjustment needed) anti-TB regimen
DTG for people living with HIV already using a first-line ART regimen
Clinical or immune failure or Switch to AZT +3TC + DTG - No evidence to support the efficacy of DTG when used
in
viral load not suppressed or Pl/r combination with an inactive NRTI backbone
Provide adherence support
Viral load supressed Substitution to TDF +3TC + DTG Substitution should be considered in the context of drug
may be considered according to supply and patient choice
nafional recommendations Substitution may conter new side-effects and interfere
with adherence
DTG regimens may be more durable in the long term
Clinically and immunologically Give priority to viral load testing No evidence to support the efficacy of DTG whenused in
stables and viral load unknown or consider other programmatic combination with an inactive NRTI backbone
or clinical indications indications provide adherence support
for substitution to DTG based ART
Stablet on suboptimal first-line Substitute to TDF +3TC+ DTG Substitution may confer new side-effects.
ART regimens Provide adherence support
3TC: lamivudine: AZT: zidovudine: DTG: dolutegravir; EFV: efavirenz; NRTI: nucleoside reverse-transcriptase inhibitor
Plr: protease inhibitor boosted withoffered
ritonavir;TDF: tenofovir disoproxil fumarate; TB: tuberculosis.
Efective contraception should be to
adult women and adolescent girls of child-bearing age or potential. DTG can be prescribed for adultwomen and
adolescent girls of child-bering age or potential who wish to become pregnant or who are not otherwise using or accessing consistent and effective
contracaptionit they have been fully informed of the potential increase in the risk of neural tube defects (at conception and until the end of the first trimester).
f women identify pregnancy after the first trimester, DTG should be initiated or continued for the duration of the pregnancy.
After adherence check and persistent detectable viral load.
Defined as stablebased on national guidelines.
Source: (24)
TABLE 7
Considerations for transition to optimal ART regimens for children
who are considered stable on ART based on national guidelines
Current regimen Weight Optimal regimen for transition Considerations
<20 kg ABC+ 3TC + LPV/r lf stable, children can be transitioned to DTG when they reach 20kg
AZT + 3TC+ NVP
AZT 3TC + EFV
20-30 kg ABC + 3TC + DTG If stable, children can be transitioned to TDF +3TC +DTGWhen
they reach 30 kg
ABC+3TC + NVP
30 kg TDF +3TC + DTG
<20 kg
No change until they reach 20 kg Transition to optimal regimens for these children is of value they
unless treatment failure occurs reach 20 kg and DTG can be used maintaining once-dallyadminis
kg ABC +3TC + DTG If stable, children can be transitioned to TDF +3TC DTG when
ABC+ 3TC + EFV 20-30
they reach 30 kg
kg TDF + 3TC +DTG
30
<20 kg
No change until they reach 20 kg Ensure the use of tablets as soon as possible to reduce.pillburaen
unless treatment failure occurs ransition from AZT +3TC +LPV/r to ABC +3TCLPVrca
be considered to reduce the pill burden and preserve the an
ABC+3TC +LPV/ advantage of NRTË's sequencing
AZT+3TC + LPV/r90.
20-30kg ABC +3TC + DTG If stable, children can be transitioned to TDE +3TC + DTG when
they reach 30 kg
30kg TDF +3TC +DTG

3TC: lamivudine; ABC: abacavir; AZT: zidovudine:DTG: dolutegravir; EFV: efavirenz; LPV/r: lopinavir/ritonavir;
NRTI: nucleoside reverse-transcriptase inhibitor; NVP: nevirapine; TDF: tenofovir disoproxil fumarate.
Source:(24)
 399
AIDS to
have A
should PER
potential
initiation
or Wno 's
childbearing potential usedn
prior tocounselled tO tine
child-bearing Pe
women of testing
pregnancy completes de
All of be should
expOsure
woman should
g dolutegravir until sheto D10the
methodexposed
(PEP) services gnan especially if
prophylaxis comprehensive set
of person, PCbedbirth controlwomendefects,
fexposure
consists of a
an
exposedassessmeni en.regnant
Ciective
neural tube
trimester.
developing
counselling on
n and risk
risk the monitored for
during the
first prophylaxis for
fwo
o5 for HlVection dependingprovision of
PEP
nrevenet aid
care;
and, combination of that
Occurredco-trimoxazole
infections (22)dose
counselling: days) trimethoprim/
(z6 jollow.-up. intections.
2aing. and short 1erm ànd Use of
the Support HIV-related fixed
(sulfamethoxazole and
protozoan inexpensive
Ent drugs, win prophylaxis a
HIV
offered. and o-trimoxazole is and and Hiv-related
ettoviral posÍ-exposure
antrero 5hould beindividuals
with drugsbacterial, fungal
toleratedreduce (2016)
bilityfor propnylaxis 1o all transmission,
and microbial variety offeasible, well HlVrecommendations
to
Post-exposure possibe. HIV a
Coverstherapy with 8.
early às potential 1or ispeople livingWHO in lable
as HIV summarized
miiated
psure
the
natt hastiours
the
based on includee he
nervention formortality. The is
co-frimoxazole mtections,
witin z eligibility should be may morbidity and
ideally possible and and ocal use of TABILE related
for
essment source whenever prevalence TOr the fHlV
bacKground co-trimoxazoie for
dalus of the
ronsideration of
prophylaxis moxt iO(20
patfeTns, posi-exposure Lse of advaiced
epidemologiCal
wartant women severe or count
iay cxposure (sexual pregnant recommended for for a CD4
Exposures that membrane cavily): (including and/or
Aduts prophylaxis is 3 or 4)
3 inciude. mucOus eye, nose of oral Co-frimoxazole (WHO stage infections are
parenteral or
splashes to
1ne
HIV disease bacterial inifiated
severe should be
exposure and risk of HIVinical and/or
may pose a breastmilk, 350 cells.m. malaria prophylaxis
and following bodily fuids
blood-stained
saliva, sectal, n&eltings where co-trimoxazole
prevslent.
stage.
or WHO discontinued
in adults
ainiolic,
cerebro8pinal, highly count clinically
are ecovery
the blood. CD4 cel be
regardless of prophylaxis mayHIV infection who
infection: lluids.
secietions andpericardial ot pleural
pOst-exposure immune
genital syiovial,
Co-frimoa2ole swomen) with evidence ol
equite pregnant iheropy, with
peritones, not fincudingantireftosviral intections are
that does positive: on sevete
bacterial sliould be
Exposure
iticlude alteady HV abievitsl suppestion,malarin and/or prophylaxis
negafive; cinical stnge.
4
proptiylasjs individual is and where co-trimOx1zole
the
exposed established to be HV n seftings
prevalent, count or WiiO
a.uhen cell
b. uhen
the
source is
nof pose
a highly
contiived
tegatdess of CDa
do children,
fluids haf saliva, Uine odoleseents
.exposure fo
bodily non-bloOd-stained chidren and recommended for intants, tnmune
infarils, and
signifant risk:
1ears,
trimoxAzole
uophylaxis isfrespective of ciinical younger than
iridividual }91, children to
exposed Co adoescents with áll ond
shouid b vencount or clinical(WfHO clinical
and su
of the post-expOsure and
to stoge
1lV stalus inilialin9,
ASSeSHent of fhe conditions, i'iotity cell
1o testing and iegstdless of CDi clinical disease
a banier where HIV years old advaneedHv
StoNid rot beemergency situalions potential H1IV r1sk
with severe or 350 cells/mn
S and/or severe
Pophyia i8. In
readily available but the testing9. post children
o 4} and/or
those wiith CI4 of malarin be
DUITIN ing is nof efuses inilial 1esting $139e 3 high prevalence propiylaxts sthould
person settings with a therapy
he exposed iniliated and Hv In co-trimoxazole
of antiretroviral
Bg Orifprophylaxis shouid be as pos5iDC.
bocterial infections.
aduithood irespective
20Le underlaken as soon continued until bacteria!
ard
CDunselling
rovision. malariä and
prevalence for both discontinued for
recommended with low
In settings co-trimaxazole prophylaxis may be
PEP regimen (25) stable arid/or
are now
PLP Tegimens ouwing 1o the satety
the
na inlections,
age and older who are clinically months
ug children 5 years ol therapy lor at least 6
e
to
exposures longer
all HIV drugs. The guidelines noare some virelly suppressed
on antiretrovira!
cells'mm.
Dy of new There and CD4 > 350
severity of Cxposure.
which2-drug ?egmen
S ssing the however, in HIV.exposed infants
ircumstances, recommended antiretroviral is reconmended
for HIV.exposed
especially when concern a00ut Co-trimoxazole prophylaxis until HIV
UCa, iOS are
unavailable or there
is
An expert shoula infants from 4-6 weeks of
age ànd siould be continued
HiV test to
by àn age-appropriate
H
problems or 1oxicity.
adherence dered.
considerd infection has been exciuded cOnpiete ccssatton of breast-feeding.
2-drug regimen is being establish final diagno0S1s alter
edif preferred HIV 3-drug PEP
regimen is raltegravir LPViris recommended as the preierred
third drug for Hiv post.
younger than 10 years.
e
400mg PO twice daily plus
Truvada (ienofovir Dr exposure prophylaxis among children
once daily. can be identitied among
emtricitabine 200mg) PO An age-appropriate aiternative regimen
1

antiretroviral pOstexposure RAL, DRV, EFV and NVP

guidelines for ATV,
2016 non-Occupational exposure to HIV
TB coinfection
ecom 400mg twice daly or HIV and
dol deither raltegravir (RAL) in combination with
tegravir DIG) 5Umg daily
(DTG} 5Omg aay ITDE) 300mg Routine co-trimoxazole prophylaxis should be administered to all
enofo
Ovidisoproxilfumaral
emtricitabine (FTC) preferred regimen in
a HIV-infected people with active lB disease regardless of CD4 cell
counts.
20Un daily as the proVides a
Dolutegravir
asoah ànd adolescents. Source: (22)
De once-daily alternative to raltegravir.
 EMERGING AND RE-EMERGING INFECTIOUS DISEASES 401
The factors responsiole ior emergence and re-e mergence water or food. The illnessis
ntious diseases are: (1) unplanned ansmitted through air,
and under- Characterized by sudden onset of fever, intense weakness,
ned urbanizatio
plation arowth; (3) poor
overcrowding and rapid muscle pain, headache, sore throat, vomiting, diarrhoea,
sanitation; (4) inadequate and in some cases
hlic health intrastructure; () resistance to antibiotics; dsn, impaired kidney and liver functions is no
both internal and external bleeding. Currently there
Pncreased exposure ot humans to disease vectors and
5pecitic treatment for this disease. However, by intensive
infection nature; (7) rapid and intense
reservoirs of supportive care, the mortality can be reduced and spread
international ravet, dnd (o) microbial genetic mutation O the disease can be prevented by instituting speciic
There is no vaccine
niection control measures.
Emerging diseases against ebola (3).
During the past 30 years, at least 30 new diseases have The United States has seen the emergence of hantavirus
emerged to threaten the health of hundreds of millions of pulmonary syndrome, characterized by respiratory tailure
Deople. For many of these diseases there is no treatment, it was first
and a case fatality rate of over 50%. Since
Cure or vaccine ana the possibility of preventing or recognized in 1993, this type of hantavirus intection has
controlling them is limited. been detected in more than 20 states in that country, and
nas also Surtaced in Argentina and Brazil. This hantavirus is
Emerging infectious diseases are those whose incidence
carried by rodents, particularly deer mice. Other
in humans has increased during the last two decades or recognized for many years in Asla,
which threaten to increase in the near future. The term also
hantaviruses have been
where they cause haemorrhagic fever with renal
refers to newly-appearing intectious diseases, or diseases
involvement in humans.
that are spreading to new geographical areas such as
cholera in South America and yellow fever in Kenya. Epidemics of foodborne and waterborne diseases due to
new organisms such as cryptosporidium or new strains of
The diseases in question involve all the major modes of
transmission they are spread either from person tO person,
bacteria such as Escherichia coli have hit industrialized
and developing countries alike. The Ol51:M strain or
-

by insects or animals, or through contaminated water or

food. The most dramatic example of a new disease is
COVID-19 in the year 2019. The ongoing COVID-19
pandemic has changed the whole world with virtual global
lockdown, social distancing and use of mask as the only
weapon against the uncontrolled spread of the disease. First
case of COVID-19 was reported in the month of November,
2019 and on 11th March, 2020, it was declared a pandemic
by the WHO. As of 19th Feb., 2021 about 110,877,097
cases with 2,453,572 deaths were reported worldwide.
Although, now vaccines are available against COVID-19, the
disease is yet to come under control. New strains of the virus
are also now in circulation (1).
AIDS, caused by the human immunodeficiency virus
(HIV).The existence of the virus was unknown until 1983.
About 38 million people are living with HV globally in
2019. 1.2 million cases with 690,000 deaths were reported
worldwide in 2019 (2).
A new breed of deadly haemorrhagic fevers, of which
tbola virus disease (previously known as Ebola
haemorrhagic fever) is
the most notorious, has struck in
Alrica. Ebola appeared for the first time in Zaire and sudan
ni976. Since then it has appeared periodically. Ebola virus
Filoviridae family and comprises of 5 distinct
mber of
pecies Zaire ebolavirus; Reston ebolavirus;udan
ebolavirus; Tai ebolavirus; and Bundibugyo ebolavirus.
e recent epidemic started in December 20
nea and spread to South Africa. By. 8th April 2015,
al ofdeaths. 25,515 cases have been reported with over
may be as high as
U00 cent. EbolaCase fatality rateperiod
per of 2-21 days, and
has incubation
cases are
Ainiective during this period. Asymptomatic through direct
Ot infective. The virus is transmitted
the blood, organs, body secretions or other
bo tn
ids of infected animals like chimpanzees, gords
E.coli was first reported in 1982 and has since then been
implicated in many serious outbreaks of diarrhoeal illness,
sometimes leading to kidney failure. The strain has been
linked to undercooked hamburger beef and unpasteurized
milk. A completely new strain of cholera, 0139, appeared in
south-eastern India in 1992 and has since spread north and
west to other areas of India, into western China, Thailand
and other parts of outh-East Asia.
The threat of a new global influenza pandemic is
increasing. Major shifts in the make-up of influenza viruses
occur every 20 years or so, triggering large epidemics in
many parts of the world, and causing many thousands of
deaths. The next such shift is expected to take place very
soon. Epidemic strains of influenza viruses originate from
China. Ihe inthuenza virus is carried by ducks, chickens and
pigs raised in close proximity to one another on farms. The
exchange of genetic material between these viruses
produces new strains, leading to epidemics of human
infiuenza, each epidemic being due to a different strain.
Currently avian H5NI is the strain with pandemic potential,
since it might adapt into a strain that is contagious among
humans. Since 1997, 478 cases with 286 deaths have been
reported to WHO. The first case was from Hong Kong. Other
countries involved are Cambodia, Indonesia, Thailand and
Viet Nam (6). In late 2002, a new disease called SARS was
reported from China with rapid spread to Hong Kong,
Singapore, Viet Nam, laiwan, and Toronto. During 2003,
n
8,422 SARS cases were reported from 30 countries with 916
fatalities (7). More recently, pandemic due to influenza A
(H1N1) 2009 strain is continuing worldwide involving
214
countries, already taking 18,156 lives. New
strains such as
those of cholera and intluenza do not follow the
usual
pattern of being more common in younger people. They
affect al age groups, since older people have not
acquired
immunity to them from previous infection.

eys, fruit bats etc. Human to human transmission
ere
ha
0od or body fluids of an infected symptomatic
or through exposure to objects (such as needles) that
En contaminated with infected secretions. It is not
s Table 1 summarizes the aetiological agents and
infectious
diseases in humans and/or animals recognized since 1973.
The year may difter from first appearance and first
identification of cases.

www.a OSA 3 AT 20Osassar

 NON-COMMUNICABLE DISEASES Males Females Both sexes
428 epithelium; (b)
Sarcomas, which 3.929,973,836 3,864,824,712 7,794,798.8d0

uterus) and from the skin the various Population 9,227,484 19,292.789
mesodermal cells constituting bone); and 10,065,305
arise from fat and Number of new
(e.g. fibrous tissue, the cancer cases
connective tissuesmyeloma and leukaemias arising from Age-standardized 222.0 186.0 201.0
(c) Lymphomas, systems.
incidence rate (World)
marrow and immune denote cancer in 18.6
cells of bone 22.6 20.4
"primary tumour is used to tumour denotes Risk of developing
cancer
The term
of origin, while "secondary and distant before the age of
the organ nodes
cancer that has spread to regional lymph a critical size, 75years (%) 5,528,8110 4,429,323 9,958,133
cancer cells multiply and reach localized to Number of
organs. When or ulcer
clinically evident as a lump disease advances, cancer deaths 84.2 100.7
the cancer is As the 120.8
in early stages. metastases Age-standardized
the organ of origin invasion and distant mortality rate (World)
symptoms and signs of 12.6 8.9 10.7
(1). Risk of dying from cancer
become clinically evident years (%)
efore the age of 75 25,721,8007 50,550,287
24,828,480
Problem statement 5-year prevalent cases
Lung Breast Breast
Top 5 most frequent Colorectum Lung
WORLD cancers excluding Prostate
to an Lung Colorectum
In the year 2020, the
global burden of cancer rose non-melanoma Colorectum
Cervix uteri Prostate
cases with 9.958 million skin cancer
Stomach
estimated 19.292 million new diagnosed were cancer ranked by cases) Liver Thyroid Stomach
common cancer
deaths. The most prostate, colon and stomach. rate of top 10 cancers by
breast followed by cancer lung, The age standardized incidence
due to cancer was cancer and mortality rate of
The most common cause of death and cancer breast. The sex, and age standardized incidence
stomach in Fig. 1 and 12.
lung, cancer liver, cancer is as follows (2) top 10 cancers worldwide are as shown
summary statistics for the year 2020
Males OFemales
47.8
Breast 14.6
Lung 31.5
16.2
23.4
Colorectum
30.7
Prostate
15. 7.0
Stomach
14.1 5.2
Liver
13.3
Cervix uteri
10.1
Thyroid
9.3 3.6
Oesophagus
Bladder 9.5 2.4

50 50 40 30 20 10 0 10 20 30 40 50 60
ASR (World) per 100,000

FIG. 1
Age standardized (World) incidence rates by sex, top 10 cancers
Source: (2)

Incidence Mortality

Breast 47.8 13.6

Prostate 30.7 7.7
Lung 22.4 18.0
Colorectum 19.5 9.0
Cervix uteri 13.3 7.3
Stomach 11.1 7.7
Liver
9.5 8.7
Corpus uteri 8.7 1.8
Ovary
6.6 4.2
Thyroid
6.6
0.43
60 50 40 30 20 10 0 10 20 30 40 50 60
ASR (World) per 100,000

FIG. 2
Age standardized (World)
Source (2) incidence and mortality rates, top 10 cancers
 CANCER 429

nce of growing and ageing populations, as

quence INDIA
Cos in the prevalence and distribution of main Registry Programme of the
s As a
changes
cer, several of which are associated with ndia, the National Cancer
ICMR provides data on incidence, mortaltaand 55 hospital
hospltai
factorsmic development, developing countries are OTcancer from 28 population-based registries and
wio-econnately affected by the increasing numbers of
sproport based registries.
of prevalent Cases
n india, in the year 2020, the number
ance
sexes combined, one-halt of all cases and is about 2,720,251, the number
of new ca
cancer are to occur in Asia ears)
,oZ4,413 and the number of deaths
851,6/8, ne
roent of 59.5 per cent estumated
deaths
global population for the year 2020
in the
8.3
Dehere of the
umary as statistical situation
ZU TOpe accounts for ZZ.8 per cent of the total country is follows
per the cancer deaths,
ases and 19.6 per cent ofofthe global population,
cent
Summary statistics 2020, India
es

Tepresents 9.7 sexes

Both
thougthe Americas' 20.9 per cent of incidence and Males FemalesS
ollowed
In contrast to other 662,903,415 1,380,004,378
cent of mortality woridwide. Population 717,100,976
1,324,413
2 per cancer deaths in Asia (58.3 per cent) 678,383
the share of of Number of new 646,030
TeAfrica (7.2 per cent) are nigher than the share cancer cases 97.1
na per cent and 5.7 per cent, respectively) 95.7 99.3
cidence (49.3 Age-standardized
the different distribution of cancer types and incidence rate 10.4
10.5
rates in these regions (3).
because 10.4
Risk of developing cancer
higher case tatality
before the age ot
The "Westernization trends: As low human-development 75 years (70
through 851,678
index (HDI) countries become more developed likely Number of 438,2 413,381
they are to
rapid societal and economic changes, cancer cancer deaths 63.1
become "westernizedAS Such, the pattern of Age-standardized 65.4 61.0
HDI settings,
incidence is likely to tollow that seen in high mortality rate 7.1
cancer incidence rate of cervix uteri Risk of dying from cancer 7.4 6.7
with likely decline in
rates of breast, years (o) o)
and stomach, and increasing
incidence betore the age ot 7 2,720,251
westernization effect is prevalent cases 1,208,835 1,511,416
prostate and colorectal cancers.
This -year Breast
result of reduction in
intection-related cancers and most frequent Lip, oral cavity Breast
a
dietary Top 5
Cervix uteri Lip, oral cavity
increase in cancers associated with reproductive, cancers excluding Lung
Ovary Cervix uteri
non-melanoma Stomach Lung
and hormonal risk factors (4). Colorectum Lip, oral cavity
to mortality skin cancer Colorectum Colorectum
For any disease, the relationship of incidence (ranked by cases) Oesophagus
an indication ot prognosis. Similar
s
incidence and mortality
condition. Thus, Source:(7)
rates indicative of an essentially fatal
being rate of top 10 cancers by
ung cancer accounts for most deaths from
cancer in thhe The age standardized incidence rate and incidence rate
World (1.7 million) annually, since
it is most invariably sex, and age standardized mortality
is as shown in Fig. 3 and 4 (7).
associated with poor prognosis. On
the other hand, per lakh population in India
fatal in men were cancer lip
appropriate intervention is often effective in avoiding The five most frequent cancers
cancer. Hence this colorectum and oesophagus,
Outcome following diagnosis of breast and oral cavity, lung, stomach, uteri, ovary, lip, oral
particular cancer, which rank second in terms of incidence,
and in women, cancer breast, incerviX were mostly tobacco
from cancer cavity and colorectum. Cancer
males
not among the top three causes of death stomach, and cancer is closely associated with
Tespectively cancers of the lung, related. n women, cervical
are ver.
consummation of marriage,
poor genital hygiene, early contact with multiple sexual
o multiple pregnancies, and
conspicuous feature of the distribution partners.It is also reported athat
breast cancer is
most
ersDetween the sexes is the male predominance
or lung metropolitan areas
proportionately on the increase in totew marriage, birth of
cancer are
OState, colorectal, stomach and liver of India. This appears to be related
late
le or oreast, age, tewer children, and shorter
more common in males. Cancer common In the first child at a late
uCn
fomo lung, cervix, uteri and stomach
are are
periods of breast-feeding, which women (8).
increasingly common
distribution
ror the most part, differences in practice among the educated urban
in exposure
the sexes are attributable to differences Facilities for screening and proper management
of cancer
ro
n ve agents rather than to variationcancers O
in tne
India. More than two-thirds
patients are grossly limited in an advanced and incurable
of
for other tumour types,
including
he difference in the sex cancer patients are already in
ànct little APpropriate strategies are
Striana colorectum, there is
relationsnip stage at the time of diagnoSIs. public awareness about
incid Generally speaking, the being developed, including
Creating
affected by sex. Thus for application or assisted
of self cancers
mortality is not cancer, tobacco control and
diagnosis of liver or oral, cervical, and breast
Pancreate prognosis following males and
screening technique for
lemalec Cancer is dismal for both
more responsive tO
herapu Other tumour types are uterine Time trends
cancers of breast, prostate and Few decades ago,
cancer was the sixth leading cause of
ervix are at
the causeOof death in only a minority of patients
death in industrialized
countries, today, it is the second
gnosed
(6) iause leading cause ot death. Ihere
are a number ot reasons for this
he unequally between ones being a longer lite expectancy,
develorburden of cance is distributed increase, the three main and the rise in cigarette smoking,
and dancer countries, with particular cancer
tunped nd developing
ypes more accurate diagnosis
iting aifferent patterns of distribution.
 430 NON-COMMUNICABLE DISEASES

Males Females
Breast
iiias 26,8
Lip, oral cavity
4.6

Cervix uteri n I8.0

Lung 7,8 .1
Colorectum
Oesophagus
6.1 3.4
Stomach
6.1 2.9
Leukaemia
4.2
Ovary
Prostate

40 30 20 10 0 0 30

ASR per 100,000

FIG.3
Age standardized incidence rates by sex, top 10 cancers in India (2020)

Incidence Mortality

Breast z3,8
13.3
Cervix uteri 18.0 L e
Lip, oralcavity
Ovary b.7

Prostate 5.5 2.7

Lung | 4.9 2 L 202d
.4
39
Colorectum 4.8 EM 2.8
Oesophagus
**
Stomach 4.5
Leukaemia 3.6 2.6

40 30 20 10 10 20 30 840
ASR per 100,000

FIG.4
Age standardized incidence and mortality rates, top 10 cancers in India (2020)
especially among males. The overall rates do not reflect the
different trends according to the type of cancer. For example,
there has been a large increase in lung cancer incidence and
the stomach cancer has shown a declining trend in most
developed countries for reasons not understood.
Cancer patterns
There are wide variations in the distribution of cancer
throughout the world. That cancer of the stomach is very
common in Japan, and has a low incidence in United States.
The cervical _cancer is high in columbia and has a low
incidence in Japan. In the South-East Asia Region of WHO,
the great majority are cancers of the oral cavity and uterine
cervix. These and other international variations in the
pattern of cancer are attributed to multiple factors such as
environmental factors, food habits, lifestyle, genetic factors
or even inadequacy in detection and reporting of cases.
Hospital data clearly indicates that the two organ sites
most commonly involved are: () the uterine cervix in
women, and (i) the oropharynx in both sexes. These two
sites represent approximately 50 per cent of all cancer cases.
Both these cancers are predominantly environment related
and have a strong socio-cultural relationship. It is also
t 0
important to note that these two kinds of cancer are easily
accessible tor physical examination and amenable to eary
diagnosis by knowledge already available. i.e., good clinica
examination and exfoliative cytology. The cure rate tor these
neoplasma is also very high if they are treated surgically a
stagesI and il. But untortunately, in most cases, the patient
present themselves to a medical facility when the disease
far advanced and is not amenable to treatment. This is th
crux of the problemn.
Causes of cancer
As with other chronic diseases, cancer has a multitactor
aetiology.
1. ENVIRONMENTAL FACTORS
Environmental factors are generally held responsio
80 to 90 per cent of all human cancers.ne
environmental factors identified sofar incu
(a) TOBACCO: Tobacco in various forms of its usage
smoking, chewing) is the major environmental caa
cancers of the lung, larynx, mouth, pharynx oesopato
oladder, pancreas and probably kidney: It has been es is no
that, in the world as a whole, cigarette smoki
 434 NON COMMUNICABLE DISEASES
motivation for changing lifestyles supported by legislative
measures like banning or restricting the sale of tobacco.
b. SECONDARY PREVENTION
Oral cancers are easily accessible for inspection allowing
early detection. If detected early, possibly at the
precancerous stage, they can be treated or cured. The
precancerous lesions can be detected for up to 15 years,
prior to their change to an invasive carcinoma. Leukoplakia
can be cured by cessation of tobacco use. The main
treatment modalities that offer hope are surgery and
radiotherapy (30). In developing countries over 50 per cent
of oral cancers are detected only after they have reached an
advanced stage (15).
The primary health care workers (village health guides,
and multi-purpose workers) are in a strategic position to
detect oral cancers at an early stage during home visits.
They can prove to be a vital link and a key instrument in the
control of oral cancer in developing countries (31)
2. Cancer of the cervix
Cervical cancer is the fourth most frequent cancer in
women with an estimated 6,04,000 new cases in 2020
representing 6.6 per cent of all female cancers (3). During
the year about 3,42,000 women died of cervical cancer,
which comes to 3.1 per cent of all deaths due to cancer in
women (3). Approximately 90 per cent of deaths from
cervical cancer occurred in low and middle income
countries. Wide variations in incidence and mortality from
the disease exist between countries. Cases and deaths have
declined markedly in the last 40 years in most industrialized
countries, partly owing to a reduction in risk factors,
but mainly as a result of extensive screening programmes.
More limited improvements have been observed in
developing countries, where persistently high rates tend to
be the rule (1).
In India, cancer cervix constitutes 9.4 per cent of all
cancer incidence among women. The age standardized
incidence rate is about 18.0 per 100,000 population. The
estimated deaths were 77,348 in 2020 (7)
NATURAL HISTORY
(a) The disease: Cancer cervix seems to follow a
progresive course from epithelial dysplasia to carcinoma in
situ to invasive carcinoma (Fig. 5). There is good evidence
that carcinoma in situ persists for a long time, more than
8 years on an average (20). The proportion of cases
progressing to invasive carcinoma from preinvasive stage is
not known it may average 15 to 20 years or longer (32).
The duration of the preinvasive stage is also not known.
There is evidence that some in situ cases will spontaneously
regress without treatment. Once the invasive stage is
reached, the disease spreads by direct extension into the
lymph nodes and pelvic organs.
Normal Dysplasia Cancer Invasive
epithelium in situ cancer
FIG. 5
Hypothetical model of the natural history of cancer cervix
(b) Causative agent: There is evidence pointing to
Human papilloma virus (HPV) sexually transmitted as
he cause of cervical cancer (33). This virus was once
upposed to produce only vegetant warts, but now
acknowledged as responsible for a much wider inical
subclinical lesions. The virus is foundd in more than95% an
the cancers. Current evidence suggests that the
necessary but not sufticient cause of the disease ian
the dius
researchers are now trying to define other co-factore
RISK FACTORS
(a)AGE: Cancer cervix aftects relatively youna.
with incidence increasing rapidly from the age of 2men
then levelling off, and tinally falling again. (b) cE5
WARTS Past and/or present occurrence of clinical L
warts has been found to be an important risk factnta
(c) MARITAL STATUS: Cases are less likely to be s
more likely to be widowed, divorced or senarngle
having multiple sexual partners. The fact that cancor of the
cervix is very common in prostitutes and practi
unknown among virgins suggests that the disease cll
linked with sexual intercourse. (d) EARLY MARRIAGE F
coitus, early childbearing ron
marriage, early and
eated
childbirth have been associated with increasing ro id
(e) ORAL CONTRACEPTIVE PILLS There is enewed
concern about the possible relationship between pill usee aand
the development of invasive cervical cancer (34). A recent
WHO study finds an increased risk with increased durati ration
of pill use and with the use of oral contraceptives high
oestrogen (35). (f) SOClO-ECONOMIC CLASS: Cancer
cervix is more common in the lower socio-economic grouns
reflecting probably poor genital hygiene.
PREVENTION AND CONTROL
(a) PRIMARY PREVENTION: Until the causativefactors
are more clearly understood, there is no prospect of primar
prevention of the disease (32). It may be that with improved
personal hygiene and birth control, cancer of the cervix uteri
will show the same decline in developing countries as already
experienced in most of Europe and North America (36).
(b) SECONDARY PREVENTION: This rests on early
detection of cases through screening and treatment by
radical surgery and radiotherapy. The 5-year survival rate is
virtually 100 per cent for carcinoma in situ, 79 per cent for
local invasive disease and 45 per cent for regional invasive
disease (20). Cancer cervix is difficult to cure once
symptoms develop and is fatal if left untreated. Prognosisis
strongly dependent upon the stage of disease at detection
and treatment
3. Breast cancer
Female breast cancer has now surpassed lung canceras
the leading cause of global cancer incidence in 2020
with an estimated 2.3 million new cases, representing
11.7 per cent of all cancer cases. It is the fifth leading cauS
of cancer mortality worldwide, with 6,85,000 deatns
Among women, breast cancer accounts for 1 in 4
cance
cases and for in 6 cancer deaths, ranking first
1 for inciden=
in the vast majority of countries (159 of 185 countries),
alne
mo
for mortality in 110 countries. There are exceptions,
notably in terms of deaths, with the disease precedea
lung cancer in Australia/New Zealand, Northern Europ
Northern America, and China (part of Eastern Asia) an
cervical cancer in many countries in sub-Saharan Africa
Incidence rates are 88 per cent higher in transt
Countries than in transitioning countries (55.9 and 29.
T00,000, respectively), with the highest incidence
80 per 100,000) in Australia/New Zealand, We
Europe (Belgium has the world's highest inclae
 NON-COMMUNICABLE DISEASES
retinopathy, nenh.
diabetes include Peonpathy
438 specific effects of among other complications.
926-929.
Lancet, 2: and neuropathy, risk of other diseases inoth
44 Pike, M.C. et al (1983).
JAMA, 246: 1559-1563 diabetes are also at increased Cerebrovascular dicng
Frisch, R.E. et al (1981). arterial and
Health, Sept-Oct, pp 8-11. heart, peripheral erectile dystunction, and non-alse,
45.
Muir, C.S. (1981). World lic
obesity, cataracts, They are also at increased
creased risk
46. 39 (3) 109-111
47. WHO (1985). WHO Chronicle, risk of some
48. WHO (1982). Bull WHO, 60 (6) 809-819. fatty liver disease. such as tuberculosis (1).
Notani, PN. et al (1977)
Int.J.Cancer, 14: 115.
437. infectious diseases,
49. (1979). Brit.J.Cancer 40: (2019)
Jussawalla, D.J. and Jain, D.K.
50.
WHO (1979). Techn. Rep. Ser.,
No. 636. Classification of diabetes
classification system for diabetes would
51. Med.J., 2: 1525
(1976). Brit.
52. Doll, R. and Peto, R.
Ideally a single purposes: clinical care, Eao
DIABETES MELLITUS facilitate three primary With this in mind, the xpe
pathology and epidemiology. system tha
metabolic best fo define a classiticationprofessiona
describes a group ofpresence group considered it
The term diabetes of and helps health
identified by the
disorders characterized and absence of treatment. The prioritizes clinical care to star
and whether or not
hyperglycaemia in the choose appropriate freatment, at the time of diagnosis
includes defects in insulin treatment with insulin, particularly is as shown in Table1(2
heterogeneous aetio-pathology of
both, and disturbances The WHO classification
of diabetes
secretion, insulin action, or metabolism. The long-term
carbohydrate, fat and protein
TABLE 1
Types of diabetes
Change from previous
Brief description classification
Type of diabetes
deficiency; Type sub-classes
1
immune-mediated) and absolute insulin removed
diabetes B-cell destruction (mostly early adulthood
Type 1
onset most common in childhood and resistance; Type 2 sub-classes
of B-cell dysfunction and insulin
Type 2 diabetes Most common type, various degrees obesity
removed
commonly associated with overweight
and
New type of diabetes
Hybrid forms of diabetes Nomenclature changed
more often has features of the
Similar to slowly evolving type in adults but
1
Slowly evolving, and retains greater previously referred to as
metabolic syndrome, a single GAD autoantibody
immune-mediated latent autoimmune
diabetes of adults B-cell function diabetes of adults (LADA)
not require insulin; No change
Ketosis-prone Presents with ketosis and insulin deficiency but later does
common episodes of ketosis, not immune-mediated
type 2 diabetes
Other specific types
Monogenic diabetes Caused by specific gene mutations, has several clinical manifestations Updated nomenclature
Monogenic defects of requiring different treatment, some occurring in the neonatal period, others
for specific genetic
B-cell function by early adulthood
Caused by specific gene mutations; has features of severe insulin resistance without defects
Monogenic defects in
insulin action obesity; diabetes develops when B-cells do not compensate for insulin resistance
Various conditions that affect the pancreas can result in hyperglycaemia No change
Diseases of the exocrine
pancreas (trauma, tumor, inflammation, etc.)
Endocrine disorders Occurs in diseases with excess secretion of hormones that are insulin antagonists No change
Drug- or chemical- Some medicines and chemicals impair insulin secretion or action, some can No change
induced destroy B-cells
Infection-related diabetes Some viruses have been associated with direct B-cell destruction No change
Uncommon specific forms of Associated with rare immune-mediated diseases No change
immune-mediated diabetes
Other genetic syndromes Many genetic disorders and chromosomal abnormalities increase the risk of No changge
Sometimes associated diabetes
with diabete
Unclassified diabetes Used to describe diabetes that does not clearly fit into other categories.
This New types of
category should be used temporarily when there is not a clear
diagnostic diabetes
category especially close to the time of diagnosis
Hyperglycaemia first detected during pregnancy
Diabetes mellitus in Type 1 or type 2 diabetes first diagnosed during
pregnancy
pregnancy No change
Gestational diabetes Hyperglycaemia below diagnostic thresholds for
mellitus diabetes in pregnancy Defined by 2013
Diagnostic criteriafor diabetes: fasting plasma glucose diagnostic criteria
27.0 mmol/L or 2-hour post-load plasma
Hbalc 248 mmol/mol glucose 211.1 mmolL or
Diagnostic criteria for gestational diabetes fasting
plasma glucose 5.1-6.9 mmol/L or L
or 2-hour post-load plasma glucose
8.5-11.0 mmol/L 1-hour post-load plasma glucose210.0m
Source (2) :
 DIABETES MELLSTCUS 439
diabetes (Insulin-dependent diabet to be
1
the disease. Its onset is
uis) is a prevalence of diabetes in 2014 was estimated ot
most severe form of prevalence
typically
.7 in adults aged 18++ years (4). The
md is usually seen in nanauals less than 30 years of dlabetes was highest in the Eastern Mediterranean kegion
unlethal unless promptiy diagnosec and treated. This the Kegion of the Americas (11% for both sexes) and

diabetes is immune-mediated in over 90 per cent

f ce ot nd
Owest in the WHO European and Western
Pacitic Kegions
md idiopathic in less thanI0 per cent cases. The rate otner
7o tor both sexes). The magnitude of diabetes and
stuction of pancreatic cell is quite variable, Rapid in are considerabiy nigner
edividuals and slow in others. 1ype 1 diabetes is
anormalities of glucose tolerance o impaet
assOciated with ketlosis in nS
nan the above estimates if the categories are also incuded
allyas untreated stale. It occurs
asting and 'impaired glucose tolerance
stly
S
children. n
ar
in
up. but e
occasionally
gnest among 10-14
occur in adults. It is
The estimated prevalence of diabetes Was
consistent across the income group
latively

alence (8% for

disorder
abolic aisc in which circulating insulin is virtually income countries showed the Oe valence
snowed
both sexes), and the upper-middle-income countries
ent. plasma glucagon, is eievated, and the pancreatic
|ls respond to al nsunogenic stimuli. Exogenous
fail to the highest (10% for both sexes) (5).
is therefore required to reverse the catabolic state,
alin
vent ketosis., reduce the hyperglucagonaemia, Unfavourable modification of lifestyle and dietary habits
and reduce that are associated with urbanization are believed to
be the
od glucose (8). development of diabetes. Ihe
most important factors for the
ype 2 diabetes is much more common than type 1 approximately twice in urban areas
prevalence of diabetes is
etes. It is often discovered by chance. It is typically than in rural population.
dual in onset and occurs mainly in the middle-aged and
A bulk of evidence from studies on migrants indicates that
rly, frequently mild, slow to ketosis and is compatible ne ethnic, presumably genetic, vulnerability ot Asians
long survival if given adequate treatment. Its clinical manifests into diabetes when subjected to unfavourable lite-
ure is usually complicated by the presence of other
styles. Population-based surveys completed recently in
ase processes. Bangladesh, India and Indonesia have shown considerable
Gestational diabetes is hyperglycaemia with blood increase in the prevalence rate of the disease in both urban
ose values above normal but below those diagnostic of and rural dwellers when compared to results obtained earlier.
petes. occuring during pregnancy. Women with Diabetic patients, if undiagnosed or inadequately treated.
ational diabetes are at an increased risk of complications develop multiple chronic complications eading to
ng pregnancy and at delivery. They and their children irreversible disability and death. Coronary heart disease and
also at increased risk of type 2 diabetes in the future. stroke are more common in diabetics than in the general
mpaired glucose tolerance (1GT) describes a state population. Microvascular complications like diabetic renal
rmediate- "at-risk" group between diabetes mellitus disease and diabetic retinopathy and neuropathy are serious
normality.It can only be defined by the oral glucose health problems resulting in deterioration of the quality of
rance test (see Table 3). life and premature death. In fact, diabetes is listed among
the five most important determinants of the cardiovascular
ulin resistance syndrome (Syndroine X) disease epidemic in Asia. Lower limb amputation are at least
obese patients with type 2 diabetes, the association of 10 times more common in diabetic than in non-diabetic
erglycaemia, hyperinsulinaemia, dyslipidaemia and individuals in developed countries, more than hali of all
eriension, which leads to coronary artery disease and non-traumatic lower limb amputations are due to
se, may result from a genetic defect producing insulin diabetes (5). Metabolic disorders in pregnant diabetic
tance, with the latter being exaggerated by obesity. t women as well as those caused by gestational diabetes
been proposed that insulin resistance predisposes to (diabetes diagnosed for the first time during pregnancy)
rglycaemia, which results in hyperinsulinaemia (which pose a high health risk, to both the mother and foetus.
or may not be of sufficient magnitude to correct the Unfortunately, there is still inadequate awareness about
rglycaemia) and this excessive insulin level then the real dimension of the problem among the general public.
Tibutes to high levels of triglycerides and increased There is also a lack of awareness about the existing
um retention by renal tubules, thus inducing interventions for preventing diabetes and the management of
rlension. High levels of insulin can stimulate complications. Inadequacies in primary health care systems,
inelial proliferation to initiate atherosclerosis (3). which are not designed to cope with the additional challenges
posed by the chronic non-communicable diseases, result in
blem statement poor detection of cases, suboptimal treatment and
RLD insufficient follow-up leading to unnecessary disabilities and
severe complications, often resulting in early death.
abetes is an "iceberg" disease. Although increase in The age-adjusted mortality rates among the people with
ine prevalence and incidence of type 2 diabetes have diabetes are 1.5 to 2.5 times higher than in the general
red gloablly, they have been especially dramatic in population (6). In Caucassian population, much of the
2lies
n economic transition, in newly industrializea excess mortality is attributable to cardiovascular disease,
es ànd in developing countries. During year 2014, thne
to be
especially coronary neart disease amongst Asian and
Cases of is estimated
d O million, diabetes worlwide90 per cent are type z American Indian population, renal disease is a major
22 of these more than contributor (6); whereas n some developing societies,
n
etess
2016, an estimated 1.6 million people died from
O high blood sugar (4). More than 80 per cent
infections are an important cause ot death. It is conceivable-
that the decline in mortality due to coronary heart disease-
aeaths occur in low and middle income countries. which has occurred in many attluent countries may be
halte
i
on or even reversed if rates ot type 2 diabetes continue to rise
iagnoaent prevalence of hyperglycaemia depends This may occur it the coronary risk tactors associated with
tic criteria in epidemiological surveys
The
used
 NON-COMMUNICABLE DISEASES
442 STRATEGY
b. HIGH-RISK
purposes, the 2-hour value after 75 g oral glucose may be strategy for type 1 diat.
used either alone or with the fasting value
(11). Automated There is no special high-risk justification for es,
possible to screen thousands of At present, there is no practical netic
biochemistry has now made it (11).
samples for glucose estimation. The criteria for the diagnosis counselling as a method of prevention
with sedentaru life
of diabetes, proposed by WHO, are given in Table 3.
Since NIDDM appears to be linked
style, over-nutrition and obesity, correction of these
Target population and its complications. Sincoal.ay
reduce the risk of diabetes
can indirectly increase the risk of
diabetes, it shotld
Screening of the whole population for diabetes is not
considered a rewarding exercise (18, 19). However, avoided. Subjects at risk should avoid diabetogenic drugs lit
screening of "high-risk" groups is considered
more oral contraceptives. It is wise to reduce tactors that promote
appropriate. These groups are: (i) those in the age group 40 atherosclerosis, e.g., smoking, high blood pressure, elevatod
programma
(ii) the triglyceride levels. These
and over; (ii) those with a family history of diabetes; cholesterol and high
may most effectively be directed at target population groups
more
obese; (iv) women who have had a baby weighing
than 4.5 kg (or 3.5 kg in constitutionally small populations);
() women who show excess weight gain during
pregnancy, 2. Secondary prevention
and (vi) patients with premature atherosclerosis. When diabetes is detected, it must be adequately treated.
The aims of treatment are (a to maintain blood glucose
PREVENTION AND CARE levels as close within the normal limits as is practicable (see
prevention Table 3), and (b) to maintain ideal body weight. Treatment is
1. Primary small balanced meals more
based on (a) diet alone
Two strategies for primary prevention have been frequently, (b) diet and oral antidiabetic drugs, or (c) diet
suggested: (a) population strategy, and (b) high-risk and insulin. Good control of blood glucose protects against
strategy (11). the development of complications, Please see in chapter 10
a. POPULATION STRATEGY "Nutrition and health" under title "Nutritional factors in
1 diabetes is
selected diseases for details.
The scope for primary prevention of type Proper management of the diabetic is most important to
limited on the basis of current knowledge and is probably
(11). However, the development of prevent complications. Routine checking of blood sugar, of
not appropriate
programmes for type 2 diabetes based on urine for proteins and ketones, of blood pressure, visual acuity
prevention and weight should be done periodically. The feet should be
elimination of environmental risk factors is possible. There is examined for any defective blood circulation (Doppler
pressing need for primordial prevention that is,
prevention of the emergence of risk factors in countries in ultrasound probes are advised), loss of sensation andthe
which they have not yet appeared. The preventive measures health of the skin. Primary health care is of great importance
comprise maintenance of normal body weight through to diabetic patients since most care is obtained at this level.
adoption of healthy nutritional habits and physical exercise Glycosylated haemoglobin: There should be an estimation
The nutritional habits include an adequate protein intake, a of glycated (glycosylated) haemoglobin at half-yearly
high intake of dietary fibre and avoidance of sweet foods. intervals. This test provides a long-term index of glucose
Elimination of other less well defined factors such as protein control. This test is based on the following rationale: glucose
deficiency and food toxins may be considered in some in the blood is complexed to a certain fraction of haemoglobin
populations. These measures should be fully integrated into to an extent proportional to the blood glucose concentration.
other community-based programmes for the prevention of The percentage of such glycosylated haemoglobin reflects the
non-communicable diseases (e.g., coronary heart disease). mean blood glucose levels during the red cell life-time (1e.
about the previous 2-3 months) (20).
TABLE 3 Self-care : A crucial element in secondary prevention is
The WHO recommendations for self care. That is, the diabetic should take a major
the diagnostic criteria for diabetes (2019) responsibility for his own care with medical guidance- e.g
adherence to diet and drug regimens, examination ot his
Measurement Diagnostic cut-off value own urine and where possible blood glucose monitoring set
Fasting venous or capillary* 27.0 mmol/L administration of insulin, abstinence from alcon
plasma glucose (126 mg/dL) maintenance of optimum weight, attending perio
2-hour post-load venous 211.1 mol/L check-ups, recognition of symptoms associated wt
plasma glucose (200 mg/dL) glycosuria and hypoglycaemia, etc.
2-hour post-load capillary** 212.2 mmol/L Table 4 shows some of the individual interventions
plasma glucose (220 mg/dL) diabetes with evidence of efficacy.
Random plasma glucose 211.1 mmol/L Home blood glucose monitoring: Assessment of cont
(200 mg/dL) has been greatly aided by the recent facility of immealai
HbA1c* 6.5% (48 mmol/mol) reasonably accurate, capillary blood glucose measutoct
either by one of the many meters now available or the a
Overnight fast of 8-14 hours. reading Haemoglukotest strips (21).
If laboratory measurement is not available, point of care,
The patient should carry an identification
"finger stick") devices can be used (they report glucose values cardotails
nis name, address, telephone number (if any) and the a
in capillary plasma). a
**
Plasma glucose is preferred in people with symptoms who are of treatment he is receiving. In short, he mus have of
suspected of having type 1 diabetes working knowledge of diabetes. All these mean
educas of
patients and their families to optimize the etfectivenes
Source : (1)
primary health care services.
 VISUAL IMPAIRMENT AND BLINDNESS 449
hygiene, and
TABLE 1 standard of personal and community
Causes of blindness in India inadequate health care services.
2015-19 National survey on blindness)
Changing concepts in eye health care
0.1 per cent from acute
active error
uncorrected 1.7 per cent Recent years have witnessed a change
ophthalmology to
akia
66.2 per cent intervention (cure) typical of clinical the folloOwing
ract untreated
complications Comprehensive eye-health care which includes
7.2 per cent
ract surgical concepts:
homatous corneal opacity 0.8 per cent
rachomatous corneal opacity 7.4 per cent 1. Primary eye care
2.8per cent field of eye
isis
per cent One of the most significant developments in the concept or
icoma 5.5per health care over the last few years has been thean eye-care
1.2 cent| of
etic retinopathy primary eye care, that is, the inclusion
0.7 per cent system. The idea of primary
component in primary health care
er posterior segment disease 5.9 per cent ingredients of a primary health
eye care, as one of the main
ther globe/CNS abnormalities 0.5 per cent
care approach to blindness, has rapidly gained acceptance the
World over. It is today recognized as a model for
eye care at the
rce:(10) protection of eye health,
community level. The promotion and
commonest eye
etinopathy of prematurity (ROP) is emerging as an together with on-the-spot treatment for the
rtant cause of childhood blindness. With the advent of diseases, are its cornerstones. The final objective of primary
rbaric oxygen and opening of large number of private eye care is to increase the coverage and quality of eye health
governmnet NICUs, the survival of the premature care through primary health care approach and thereby
ies (born before 30 weeks of gestation and 1500 grams improve the utilization of existing resources.
eight at birth) has improved considerably. These babies
at risk of developing ROP and there is dire necessity to 2. Epidemiological approach
te awareness not only in public but also amongst The epidemiological approach which involves studies at
nalmologists and paediatricians to detect and treat ROP the population level has been recognized. It focuses, among
me. other things, on the measurement of the incidence,
prevalence of diseases and their risk factors. The local
demiological determinants epidemiological situation will determine the action needed.
a) AGE: About 30 per cent of the blind in India are said
se their eyesight before theyreach the age of 20 years, 3. Team concept
many under the age of 5 years. Refractive error, In many developing countries, there is only one eye
homa, conjunctivitis and malnutrition (vitamin A specialist for more than a million people. Increasingly,
ciency) are important causes of blindness among therefore, health care leans on the use of auxiliary health
aren and the younger age groups; cataract, refractive personnel to fill many gaps. In India this gap is filled by
, glauecoma and diabetes are causes of blindness in village health workers, ophthalmic assistants, multi-purpose
dle age; accidents and injuries can occur in all age workers, and voluntary agencies.
ps, but more importantly in the age group 20 to 40
rs. (b] SEX :A higher prevalence of blindness is reported 4. Establishment of national programmes
males than in males in India. This has been attributed to Another important development in connection with the
gher prevalence of trachoma, conjunctivitis and cataract prevention of blindness has been the establishment of
ng females than in males (12). (c) MALNUTRITION:
national programmes. Many of these programmes were first
nutrition as a cause of blindness was hardly recognized
years ago. It is closely related not only with low vitamin
a started by voluntary agencies concerned with blindness
prevention (e.g., eye camps) and some of them focused on a
ntake, but also with infectious diseases of childhood single disease, such as trachoma. The increasing recognition
ecially measles and diarrhoea (which precipitate of the primary health care approach to blindness resulted in
uition. In many cases protein energy malnutrition comprehensive national programmes for the prevention of
is also associated with blindness. Severe blinding blindness (13) from all causes.
1eal destruction due to
vitamin A deficiency (e.9
omalacia) is largely limited to the first 4-6 years of life Prevention of blindness
epecially frequent among those 6 months to 3 years The concept of avoidable blindness (i.e., preventable
e. fd) OccUPATION: It has long been recognized that or curable blindness) has gained increasing recognition
working in factories, workshops and cottage during recent years. A great many ot the causes of blindness
dre prone to eye injuries because of exposure to lend themselves to prevention and/or control whether by-

airborne particles, flying objects, gases, fumes, improving nutrition, by treating cases of intectious diseases,
nusually welding flash), electrical flash, etc. Many or by controlling the organisms which cause infection, or by
including doctors are known to have developed improving satety conditions particularly on the roads, at
re
Waves,
cataracts while exposed to X-rays, ultraviolet rays
(e) SOCIAL CLASS: There is a close
work or in the home (14).
nship between The components for action in national programmes
the incidence of blindness and socio- for
omic status. Surveys indicate that blindness is the prevention of blindness comprise the following:
more prevalent
0-do (12),. (6) in the poorer classes than in the . INITIAL ASSESSMENT
SOCIAL FACTORS: Many people lose
eyesight ecause The first step is to assess the magnitude,
of meddlesome ophthalmology by
distribution and causes of blindness within the geographic
cks
ne basic social factors are ignorance, poverty, oW country or
 shows the reported number of accidental
ACCIDENTS AND INJURIES 455
Table 3 deaths
es in India.
causes INDIA
main
by In 2017, 218,876 deaths due to road injuríes occurred in
TABLE 33
Renorted number of acciderntal deaths in ndia, with an age-standardized death rate for road injuries
O .2 deaths per 100,000 population, which was mucn
India by main cause (2014-2015) nigher in males (25.7 deaths per 100,000) than in females
(8.5 deaths per 100,000). The number of deaths due to road
No. of Deaths
Cause njuries in India increased by 58.7 per cent from 1990 to
2014 2015 Z017, but the age-standardized death rate decreased
Slightly, by 9.2 per cent. In 2017, pedestríans accounted tor
Natural calamity 20,201 10,510 6,729 (35.1 per cent) of all deaths due to road injuries,
Unnatural causes 4,31,556 4,02,947 motorcyclists accounted for 67,524 (30.9 per cent), motor
Collapse of structures 1,821 1,885 vehicle occupants accounted for 57,802 (26.4 per cent), and
Drowning 29,903 cyclists accounted for 15,324 (7.0 per cent). India had a
29,822
Electrocution 9,606
higher age-standardized death rate for road injury among
9,986 motorcyclists (4.9 deaths per 100,000 population) and
Explosions 194 831 cyclists (1.2 deaths per 100,000 population) than the global
Falls 15,399 16,759 average. Road injury was the leading cause of death in
Factory/Machine accidents 797 695 males aged 15 to 39 years in India in 2017, and the second
19,513 leading cause in this age group for both sexes combined.
Fire 17,700 The overall age-standardized death rate for road injuries
Fire arms 633 736 varied by upto 2.6 times between states in 2017. Wide
Sudden deaths 26,526 35,023 variations were seen between the states in the percentage
Killed byanimals 886 951 change in age-standardized death rate for road injuries from
1990 to 2017, ranging from a reduction of 38.2 per cent in
Mines or quarry disaster 210 118
Delhi to an increase of 17.0 per cent in Odisha. If the trends
Poisoning 22,587 26,173 estimated upto 20 were to continue, no state in India, or
Stampede 178 480 India overall would achieve the SDG 2020 target in 2020, or
Suffocation 1255 1,427 even in 2030 (12).
Traffic accidents 1,62,107 1,77.423
Risk factors (11)
Other causes 11,375 6,774
Causes not known 21,551 15,165 Speed
4,13,457 An increase in average speed is directly related both to
Total(Natural+Unnatural) 4,51,757
the likelihood of a crash occurring and to the severity of the
Source: (9) consequences of the crash. Some other facts are as below.
Pedestrians have a 90% chance of surviving a car crash
TYPES OF ACCIDENTS
preolop at 30 km/h or below, but less than a 50% chance of
surviving an impact of 45 km/h or above.
1.Road traffic accidents 30 km/h speed zones can reduce the risk of a crash and
are recommended in areas where vulnerable road users
n many countries, motor vehicle accidents rank first are common (e.g. residential areas, around schools).
ainong all fatal accidents. Every year almost 1.25 million
people die from road accidents in the world. In addition, for Apart from reducing road traffic injuries, lower average
every death, traffic speeds can have other positive effects on health
there are as many as 20-50 non-fatal injuries
and 10-20 serious injuries requiring long periods ot outcomes (e.g. by reducing respiratory problems
associated with car emissions).
epensive care, nursing and treatment. Road traffic fatalities
rateis higher in younger age groups. Children and young
Drink-driving
people under the age of 25 years account for over 30 per
Drinking and driving increases both the risk of a crash
OT those killed and injured in road accidents (10, 11)
and the likelihood that death or serious injury will result.
age, males are more likely to be involved
From
oung The risk of being involved in a crash increases
d traffic crashes than females. Among3 young driverS,
as likely significantly above a blood alcohol concentration (BAC)
tobe lii ne age of 25 years are almost times of 0.04 g/d
Killed in a car crash as young females (
Nearly are Laws that establish BACs of 0.05 g/dl or below are
Vulnerahi 4 per cent) of those dying on roads ana effective at reducing the number of alcohol-related
le road users like pedestrians, cyclists crashes
are
Compared to cars the two-wheelers
sta sTS. riders in Enforcing sobriety check-points and random breath
accidond. and provide little protection for their can lead to reductions in alcohol-related crashes
wheelers are more testing
aeveloped
equently involved countries, four by about 20%, and have shown to be very cost-effective.
in accident
ore than road traffic Motorcycle helmets
accidents cent deaths that result from
90 per cer
occur in low countries. Even
Din high-incom and middle-income lower socio
Wearing a motorcycle helmet correctly can reduce the
onomic backgrounds countries, people from involved in risk of death by almost 40% and the risk of severe injuryy
0ad trafficaccidents are more likely to be by over 70%.
(11).
 NON-COMMUNICABLE DISEASES
460
3. Do not apply ice because it deepens the injury.
it may lead
4. Avoid prolonged cooling with water because
to hypothermia.
5. Do not open blisters until topical
antimicrobials can be
applied, by a health-care provider.
Do not apply any material directly to the wound
as it
6.
might become infected.
7. Avoid application of topical medication until the
patient
care.
has been placed under appropriate medical
Falls
Globally, falls are a major public health problem. An
it the
estimated 646,000 fatal falls occur each year, making
after
second leading cause of unintentional injury death, falls are
road trafftic injuries. Though not fatal 37.3
million
falls are
severe enough to require medical attention. Such
million DALYs lost. Over 80% of
responsible for 17
related fatalities occur in low and middle-income countries,
with regions of the Western Pacific and South East
two-thirds of these deaths. In all
accounting for more than
world, death rates are highest among adults
regions of the
over the age of 65 years (18)
Falls are responsible for the largest number of hospital
visits for non-fatal injuries, especially for children and young
adults. Falls from rooftops, balconies, windows and stair
cases are common. Factors specific to SEAR countries are
falls from trees of workers picking fruits or coconuts, tapping
toddy, children falling from rooftops while flying kites, high
incidence of falls among construction and forestry workers.
As life expetancy increases in these countries, the incidence
of hip and other fractures due to fall among the elderly are
also assuming greater proportions (19)
Some of the risk factors include (18)
occupations at elevated heights or other hazardous
working conditions;
alcohol or substance use;
sOcio-economic factors including poverty,
overcrowded housing, young maternal age;
underlying medical conditions, such as neurological,
cardiac or other disabling conditions
side-effects of medication, physical inactivity and loss
of balance, particularly among older people;
unsafe environments, particularly for those with poor
balance and limited vision
Prevention (18)
For children, effective interventions include multifaceted
community programmes; engineering modifications of
nursery furniture, playground equipment, and other
products; and legislation for the use of window guard
For older individuals, fall prevention programmes can
include a number of components to identify and modify risk,
such as:
screening within living environments for risks for falls;
clinical interventions to identify risk factors, such as
medication review and modification, treatment of low
blood pressure, Vitamin D and calcium supplementation,
treatment of correctable visual impairment;
home assessment and environmental modification for
those with known risk factors or a history of falling
prescription of appropriate assistive devices
devices to
to address fromus
physical and sensory impairments;
prese of a
body
muscle strengthening and balance retraining rubule
by a trained health professional;
Early
Poisoning
Poisoning was responsible for an estimated 250 0
during the year 2008 worldwide. In India 0
deaths about
28,012 poisoning deaths were reported during the year
2010 (20). The most common agents responsible tor
poisoning are pesticides, kerosene, prescription drugs and
household chemicals. Pesticides are widely used in many
countries where agriculture is an important part of atha
economy. Reports from India, Indonesia, Sri Lanka
Thailand indicate that common availability and use of toxic
pesticides is responsible for intentional and unintentionsl
morbidity and mortality.
fall- In Sri Lanka, pesticides are one of the main agents used
in attempted suicide in rural areas.The use of
Asia organophosphorous insecticides in suicide events has heon
reported to be as high as 20-30 per cent. Paraquat
intoxication is known to cause irreversible damage in
patients. Many countries also report accidental ingestion of
kerosene as a leading cause of poisoning, especially among
children (19). A study from Thailand revealed that 54
per
bite
cent of cases of poisoning among pre-school children
involved therapeutic drugs.
Snake bite
Snake bite is a neglected public health issue in many
tropical and subtropical countries. About 5 million snake
bites occur each year, resulting in upto 2.4 million
envenomings (poisoning from snake bites) at least 94,000-
125,000 deaths and around 400,000 amputations and other
permanent disabilities. Most of these occur in Africa, Asia
and Latin America. In Africa alone there are an estimated
1 million snake bites annually with about half needing women
treatment. This type of injury is often found among
children and farmers in poor rural communities in low and
middle-income countries (21).
The outcome of snake bite depends on numerous factors,
including the species of snake, the area of the body bittern
ot
the amount of venom injected, and the health condition
the victim. Feelings of terror and panic are common ate
snake bite and can produce a characteristic set of symptoO
mediated by the autonomic nervous system, such asa
tachycardia and nausea. Bites from non-venomous snak
can also cause injury, often due to lacerations caused by tne
snake's teeth, or from a resulting infection. A bite may ai
trigger an anaphylactic reaction, which is potentially fae
First-aid recommendations for bite depends on the snar ted
inhabiting the region, as effective treatment forbite ininc
by some species can be ineffective for others.
The venom of poisonous snakes may be predominantly cause
neurotoxic or predominantly cytolytic. Neurotoxins
respiratory paralysis and cytolytic venoms causeo
destruction by digestion and haemorrhage au the
haemolysis and destruction of the endothelial lininge
blood vessels. The manifestations of rattlesnake and
envenomation are mostly local pain, redness, swenate
extravasation of blood. Perioral tingling, merai allic
may
nausea, and vomiting, hypotension and coagu
also occur. Neurotoxic envenomation maycauamitted toss
em
dysphagia, diplopia, and respiratory failure. ven
 ACCIDENTS AND INJURIES 461
some of cobras, almost all vipers cause
necrosis
m
from tissue. Muscle tissues begin to die throughout more than 2 years old, 0.5 mg/kg, maximum 2 mg/k
muscle the as required
of and it results in ulation of myoglobin in
the renal day) can be given every 4-6 hours by mouth drugs
body which leads to acute renal failure. not aspirin or non-steroidal anti-inflammatory
bules which can cause bleeding).
utes that a patient has severe envenoming (22): for antivenomn
Early clue Antivenom if the patient fulfils criteria skills, equipment,
jdentified as a very dangerous one; Teatment and if the necessary
a
antivenom, adrenaline and other necessary drugs are
apid early extension of local swelling from the site skills include ability to
of available, give antivenom. These
the bite; agnose local and systemic envenoming, set up
identity
arly tender enlargemen of local lymph nodes, ntravenous infusion or intravenous injection,
icating spread of venom in the lymphatic system;
indica ne early signs of anaphylaxis andrepeated treat it with
Farly systemic symptoms: collapse (hypotension, shock), intramuscular adrenaline. Re-asess for dose(5)
to a
nausea, vomiting, diarrhoea, severe headache, of antivenom. If no antivenom is available, transter
saviness" of the eyelids, inappropriate (pathological) hospital.
drowsiness or early ptosis/ophthalmoplegia; patient is in shock/hypotensive give cautious
.theIntravenous fluid challenge (adult 250-500 ml of 0.9%
Early spontaneous systemic bleeding;
brown/black urine. saline) to correct hypovolaemic shock.
Passage of dark
6. the patient has evidence of respiratory paralysis give
fOxygen
MANAGEMENT AT COMMUNITY OR by mask, consider atropine and neostigmine
VILLAGE LEVEL (23) and transfer to a hospital. It is assumed that assisted
ventilation other than by a tight-fitting face mask
connected to an anaesthetic (Ambu) bag will not be
A. First-aid possible at this level.
The Government of India developed a national snake 7. If the patient is oliguric initiate conservative
hite protocol in 2007 which includes following advice: management
1Reassure the patient. 70% of all snake bites are from 8. The bite wound: if necrotic, tampered with (incisions
non-venomous species. Only 50% of bites by venomous etc.) or obviously septic, give antibiotics and tetanus
species actually envenomate the patient; prophylaxis.
2. Immobilize in the same way as a fractured limb. Use 9. Assess the need and feasibility of transporting the patient
bandages or cloth to hold the splints, not to block the to a higher level of the health service (see A above)
blood supply or apply pressure. Do not apply any especially in case of
compression in the form of tight ligatures, they don't a. Substantial bleeding, 20WBCT still positive (non-
work and can be dangerous; clotting) 6 hours after initial antivenom dose
3. Do not give alcoholic beverages or stimulants. They are b. Progressive paralysis (muscle weakness) or respiratory
known vasodilators and they speed up the absorption of difficulty
venom; C. Reduced urine output
4. Remove any items or clothings which may constrict the d. Anaphylaxis unresponsive to adrenaline
bitten limb if it swells (rings, bracelets, watches, e. Shock/hypotension unresponsive to fluids
footwear, etc.); f. Severe local necrosis or signs suggestive of
5. Do not incise or manipulate the bitten site. Do not apply compartment syndrome
ice; and 10. Discourage the use of ineffective and potentially harmful
6. Transport the patient to a medical faculty for definitive drugs (e.g. corticosteroids, antihistamines, and heparin).
treatment.
C. At the District Hospital (23)
B. At the Rural Clinic, Dispensary, Health Post, Proceed as in B above plus:
or Primary Health Centre 1. Assessment carry out a more detailed clinical and
1. Assess
for signs of local and systemic envenoming: carry assessment including biochemical and
Out a simple medical assessment including history and haematological measurements, ECG or radiography, as
simple physical examination local swelling, painful indicated.
tender enlarged local lymph glands, persistent bleeding 2. Antiuvenom : if no antivenom is available, transfer to a
from the bite wound, blood pressure, pulse rate, hospital that has antivenom or treat conservatively; this
bleeding (gums, nose, vomit, stool or urine), level of may require transfusion of blood or fresh frozen plasma.
consciousness, drooping eyelids (ptosis) and other signs
of paralysis. Monitor these signs hourly. 3. Analgesia (see B above) and, if required, consider
(20WBCT), stronger parenteral opioid drugs as required, all with
2. Check: 20
minute whole blood clotting test great caution (e.g. subcutanous, intramuscular or even
urine examination (appearance, sticks testing for blood intravenous pethidine, initial adult dose 50-100 mg
etc.). Identify the snake or a photo of it (if brought).
children 1-1.5 mg/kg; or morphine, initial adult dose
naigesia give analgesia by mouth if required: 5-10 mg; children 0.03-0.05 mg/kg,).
Paracetamol (acetaminophen) (adult dose 500 mg to
1g
mg/kg, 4. If the patient has evidence of local necrosis (gangrene)
ldXimum, 4g in 24 hours; children 10-15 give tetanus toxoid booster, antibiotics and do surgical
(adult
aximum 100mg/kg/day) or codeine phosphatechildren debridement of dead tissue.
Ose 30-60 mg, maximum 240 mg in 24 hours;
 462 NON-COMMUNICAB1.E DISEASES
www.m
5f the patient has evidence of bulbar or respiratory
paralysis insert endotracheal tube, laryngeal mask
airway or i-gel aiway. If there is evidence of respiratory
failure, assist ventilation manually by anaesthetic
(Ambu) bag or mechanical ventilator
6. If the patient has evidence of acute kidney injury: treat
with peritoneal dialysis. If this is not available, transfer to
a specialized hospital.
7. If the patient is bleeding severely or is already seriously
anaemic cross-match and transfuse.
8. Rehabilitation: encourage exercising of bitten limb.
D. At the Referral (Specialized) Hospital (23)
Proceed as in B and C above plus
1. More advanced surgical management of local necrosis
(e.g. split skin grafting).
2. More advanced investigations including bacterial
cultures and imaging (CT scans) as indicated.
3. If the patient has evidence of acute renal failure
peritoneal or haemodialysis or haemofiltration.
4. Implement rehabilitation by physiotherapists.
Strengthening of health system in managing snakebite
To reduce complications and deaths from snakebites,
health systems need to be improved at various levels. The
government must develop a policy for snakebite, making it a
notitiable disease, developing a snakebite programme that
includes standard treatment guidelines, training of health
personnel and ensure an adequate supply, distribution and
storage of good quality antivenom.
ANTIVENOM (22)
Until the advent of antivenom, bites from some species of
snake were almost universally fatal. Despite huge advances
sin emergency therapy, antivenom is often still the only
effective treatment for envenomation. The first antivenom
was developed in 1895 by French physician Albert Calmette
for the treatment of Indian cobra bites. Antivenom is made
by injecting a small amount of venom into an animal
a
(usually horseor sheep) to initiate an immune system
response The resulting antibodies are then harvested from
the animal's blood.
Antivenom is injected into the person intravenously, and
works by binding to, and venom enzymes. It
neutralizing
cannot undo damage already caused by venom, so
antivenom treatment should be sought as soon as possible.
Modern antivenoms are usually polyvalent, making them
effective against the venom of numerous snake species.
Pharmaceutical companies which produce antivenom
target their products against the species native to a
particular area. Although some people may develop serious
adverse reactions to antivenom, such as anaphylaxis, in
emergency situations this is usually treatable and hence the
benefit outweighs the potential consequences of not using
antivenom.
3. Industrial accidents
There are approximately 580 million workers in the
South-East Asia Region. Approximately 60-80 per cent of
these workers are employed in agriculture, fisheries, home
industries, and small-scale units. Injuries due to these
occupations result in an estimated 120 million injuries and
200,000 deaths per year (19).
Though reliable estimates tor work related injuries
deaths in the Region are not available, partlu and
majority of the workers are employed in
sectors, few studies indicate that nearly one perorganized
deaths and 10 per cent ot permanent impairment restulof
agricultural injuries. Agriculture workers are exposed tOm
variety of physical, chemical towide
sticide and fertili:
biological (animal bites and animal related iniurioer,
mechanical injuries. The estimates from agriciult re nd
vary from 22-29 per 1000 workers. The incidence injury
injury among agriculture workers in India is estimatedrate
to
116 per 100,000 workers. In a study population 23.000
of
rural Haryana, nearly 31 per cent of the injuries were
to agricultural activity (24). Of these, serious injuries
n
were
caused by mechanized equipment and tractors (19)
Rapid industrialization has also resulted in mortalituan.
morbidity of many workers in hazardous industries.
The unique features common to the workplace
in this
region are that the manual labour content is high
and tho
man-machine interaction 1S unsafe. In addition, there is
greater emphasis on attempts fo, change the worker's
behaviour, but designs that provide automatic protection
ate
ignored. Children and people who are challenged physicallu
as well as mentally are at a greater risk ot encountering
Occupational injuries (19).
4. Railway accidents
With the increase in number of trains and passengers, the
increase in the number of accidents and casualties resulting
therefrom is not unexpected. During 2010, about 30,576
people died of railway accidents in India (9) The main
factor involved in railway accidentsis human failure.
5. Violence
Homicide and collective violence account for around
10% of global, injury-related death. In 2016, there were an
estimated 477,000 murders. Four fifths of homicide victims
are men, and 60% of victims, males. ze 15 44 The low
and middle-income countries of the Region of the Americas
has the most homicides, with 28.5 per 100,000 population,
while the lowest murder rate, almost 14 times lower (2.1 per
100,000 population), is found in the low- and middle
income countries of The Western Pacific Region (25
Violence is reported to be increasing rapidly.ltalsofollow
the same epidemiological pattern as any other disease (host,
agent and environment), i.e. a motivated person who
injures; a suitable target; and a suitable environmentor tne
absence of a guardian, all coinciding in timne and space
Often, it may only be possible to initiate steps for prevention
after an episode of violence has already taken iplace
Some of the risk factors for violent behaviour are (9
or
Exposure to violence and societal acceptability or
Violence as a means to solve problems. The image
violence as an acceptable and effective tool for solving
o
problems, whether across international borders,rea
street, or around the home, may spill overinto
the
behaviour;
Availability of lethal weapons likefire-arms
Significantly increases the possibility of.both fataland
non-fatal injuries;
linked to
Consumption of alcohol and other drugs 15n veral
almost 2/3 of cases of violence accordingtO
studies. 11
 4750
NATIONAL. LPROSY "ERADICAION" PROGHAM.

Implementation Referral
&
Village health Supervision self-care practices Neuritis
sanitation committee Supervision use of MCR
(GKS) ASHA, PAL Reaction
Supervision of ulcer & dressing Disability
carried out by patient Ulcer

Implementation
Referral
Self-care advice
Reaction
Sub Centre
Advice to RCS cases
Disability
Monitoring& supervision of
ASHA activities. Neuritis
FollowW-up L
-Ulcer

Sector PHC

Implementation
Manage reactions Referral
Ulcer Lepra reactions difficult to manage
dressing/technology transfer
Identify or refer patient needing RCS Complicated ulcer
Block PHC
Supply MCR foot-wear to needy patient -Eye problems
Reconstructive surgery cases
Advice to reconstructive surgery cases Persons needing Gr-l foot-wear
Advise to self care
Follow-up of RCS, Lepra reaction
Counselling

mplementation
Management of complicated Referral
ulcers Refer difficult
District Hospitall Management of lepra ulcer cases
apex group
9
reactions Refer for
Screening cases for RCS reconstructive
Diagnosis of difficult to surgery
diagnose cases/relapse case
skin smear/RCS

Implementation Referral
anagement of lepra Refer for
reactionsS reconstructive
Supply of foot-wear surgery/follow-
up of RCS.
District
Nucleus

Reconstructive Surgery Centre Implementation

Reconstructive surgery/amputation/RCS training
mplementation Follow-up after reconstructive surgery
Referral
Supply of foot-wear to district nucleus.
15

FIG. 1
SOuTçe{12) Referral System in NLEP
 NATIONAL TB ELIMINATION
PROGRAMME 477
completion rates. supply
of leprosy is also part of treatment to increase the treatment
into the basic problems strengthened to provide assured supplyot
Reseas of the NLEP. This is mainly carried out in the of drugs was also system (16).
sector, viz. tne central JALMA Institute of arugs to meet the requirements.of the
ent
:ernmeAOra and the Central Leprosy Teaching and The objectives of the RNTCP are
athingeipu, Cnennai supported by . cent cure rate of
Pn Institute Achievement of at least 85 per
Training and Reierral lnstitutes at Aska (Orissa), through DOTS invoiving
Intectious cases of tuberculosis,
gional and Gouripur (West Bengal).
or (Chhattisgarh) peripheral health functionaries; and quality
apur finding activities through
2. Augmentation of case least 70 per cent or
EP Agencies Anti-Leprosy Association sputum microscopy to detect at
International Federation of estimated cases.
The In India, ILEP is coOuntry in a
actively involved as partner in NLEP introduced in the
Mission, Damien The revised strategy was over thne
nstituted by 10 agencIes viz. ine Leprosy Leprosy Relief, has expanded rapidly
phased manner. The RNTCP it covers the whole country.
oundation of India Irust,
Netherland
Lepra India, ALES, years and since March 2006., second phase in which
Gorman Leprosy Keliet Association,
American Leprosy RNICP has now entered into it's made to date,
AIFO. Fontilles-India, AEKF-India and he
the programme aims
to consolidate the gains
access and to
support in ihe 1orm of planning, activities and
Mission. ILEP 1s providing To wide services in
terms of
o1 the programme. capacity the wIder
onitoring and supervision achievements. The new initiatives and
care staif, EC, providing re- sustain the to provide standardized
building of general health
socio-economic collaboration with other sectors aim to all TB patients
surgery services and treatment and diagnostic facilities from which they seek
constructivee
aifected with eprosy. 36 NGOs facility
rehabilitation of persons irrespective of the health care
for disability correction envisages improved access to
conducting re-constructive surgeries ireatment. The RNTCP also
supporied by ILEP (1). slum dwellers and tribal
in leprosy afected
persons are also marginalized groups such as urban
Governiment Organizations have been involved in groups etc.
infrastructure already established by
Non provided
prograrmme for many decades and have RNTCP is built upon
the
the burden of leprosy. tuberculosis programme, while
valuable contribulion in reducing from the previous national the internationally
Presently. 54 NGOs are getting gran-in-aidserve in incorporating the elements of
SET scheme. NGOs
Government of India under recommended DOTS.
sluims. industrial/labour Revised National TB Control
remote, inaccessible areas, urban groups. IEC, DOTS strategy adopted by
populafion the following five main
population and other marginalized relerral, and Programme initially had
prevention of disability, case detection
and
are some important componcnts:
follow-up for treatment completion administrative commitment.
1. Political will and
taken up by NGOs (1),.
assured sputum smear microscopy.
activities
is passing through
an
The leprosy scene in India 2. Diagnosis by quality short course
a high burden country of quality assured
impoitant phase of fransition
from 3. Adequate supply
-
pariially
leprosy toa relatively low
burden county, from a chemotherapy drugs.
more integraied one, om observed treatment.
erucal programme to a 1or cposy 4. Directly
programme aimed at increase in coverage monitoring and accountability.
ana iom
5. Systematic
lo one of sustaining quality services, WHO and
Ces
Enralization to decentralization (15). In 2006, STOP
TB strategy was announced by
Leprosy Strategy components are as follows:
WHO has announced Global adopted by RNTCP The
a leprosy-free woria 1o and enhancement.
"Accelerating towords Pursuing quality DOTS- expansion
2020: reducing the disease burden due
to leprosy. PiCase -
MDR-TB.
er
Teler to page 358 for delails.
Addressing TB/HIV and
Contributing to health system
strengthening.

LNATIONAL TB ELIMINATION PROGRAMME Engaging all care providers.

communities.
has been in -Empowering patients and (diagnosis, treatment,
Tuberculosis Programme (NTP) success Enabling and promoting research
onal
ralion since 1962.lowHowever,
the treatment a rales
cepiably and the death and default was vaccine).
piloting the
remai resistant initiatives like developing and Guidelines,
thros high. Spread of multidrug Many of the
National Airborne Intection Control
the sifuation. feasibility of
Eing to further worsen strategy for "Practical Approach to
in order to
overcome these lacunae,to he TB developing and piloting
examples of initiatives taken by RNTCP
R, new thrust Lung Health' are the
VeTnment of India decided to givea the assistance comprehensive strategy of SToP TB (16).
NTP with under the
by revitalizing the
control activities
om int es by
oncies. Theformulated, In 2014, the
World Health Assemblyby unanimously "End TB
ulated, adoplea Ttne
global IB epidemic
Internaogramme (RNTCP) thus Teatment Treatment approved to end programme with vision of a world with
ecommended Directly Observed a Strategy", a 20 year to TB. For details
nort-core most systemauc and sultering due
CoS1-effSe {DOTS) strategy, as the TB control zero death, disease
page 233.
the reter to
10 revitalize
Os1-eifective approa administrative please
and TB targets, the
programme has
rammein India Political organized and In view of End Tuberculosis Contr
nment, to ensure the provision of Kevised National
was obtained.
Adopuon
was been renamed from to National luberculosis Elimination
B control services (RNTCP)
Smear reliable and early diagnosis Programme (NTEP).
Programme
Py 1or general neal
ecedin decentralized manner in the rovision of
es, DT
Owas adopted as a stralegy io

wwwwwe.wmwwiw

wwwwww
478 HEALTH PROGRAMMES IN INDIA

NTEP Organogram (17) accountable to the state government, technically follou

NTEP structure comprises of five levels: National, state,
district, sub-district and peripheral health institution levels as
shown in Fig. 2 (17).
National level
Central TB Division (CTD) manages the National TB
Control Programme for the entire country at the central level
under AS&DG (RNTCP & NACO) through a national
programme manager, Deputy Director General TB (DDG
TB). The financial and administrative control of the
programe is managed by the Joint Secretary from the
administrative arm of the MoHFW.
The CTD is supported by a National TB Institute (NTI)
Bengaluru, six National Reference Laboratories (NRL)
including NTI, National Institute for Research in
Tuberculosis (NIRT), Chennai, National Institute of
Tuberculosis and Respiratory Diseases (NITRD), Delhi,
National Japanese Leprosy Mission for Asia (JALMA),
Institute for Leprosy and other mycobacterial diseases, Agra,
Regional Medical Research Centre, Bhubaneshwar and
Bhopal Memorial Hospital & Research Centre (BMHRC),
Bhopal. The CTD is also supported by National Task Force
for colaboration of Medical Colieges activities in the country
through ZTF/STE
Various committees of experts to guide the programme at
different levels on technical & policy matters are there
supporting Central TB Division.
State Level
The states have total ownership and accountability for
TB
the control in their state. State health society or its
equivalent under National Health Mission of the state
manages the TB control programme. A full-time State
Tuberculosis Officer (STO), trained at national level and
based at the State TB Cell (STC), is responsible for planning,
training, supervising and monitoring the programme in all
the districts of their respective states. STO is administratively
Ministry of Health &
Supporting facilities
Family Welfare
- National Institutes (3)
National Reference Central TB Division
Laboratories (6)
instructions of the CTD, and coordinates with CTD he
districts, and is assisted by other chnical & secretarial the
stalf.
State TB cell is being supported by State TB Trainina:
Demonstration Centre (STDC) in many states throucht
three units -a training unit, supervision and monitorine
and an Intermediate Reference Laboratory (IRL) supporting
s
an effective quality assurance system of the sputum smea
microscopy network and laboratary services for PM
(molecular DR testing and C&DST) in the State. Operation tional
Research is also a component of STDC.
Each state also has one fully operational State Drug Storo
(SDS) for each 5 crore of population. It is responsible for
effective management of medicines and other logistics, and
ensuring uninterrupted supply of good quality 1st & 2nd lino
anti-TB medicines for adults and paediatric population.
District level
The key level for the management of primary health care
services is the district. The Chief District Health Ofice
(CDHO)/Chief District Medical Officer (CDM0)/Civil
Surgeon or an equivalent functionary in the district is
responsible for all medical and public health activities
including control of TB. The District. Tuberculosis Centre
(DTC) is the nodal point for TB control activities in the
district. A full-time District Tuberculosis Officer (DTO),
trained at national level & based at the DTC, is responsible
for planning, training, supervising and monitoring the
programme in the district. DTO is assisted by othertechnical
& secretarial staff. The primary role of the DTC is a
managerial one.
Sub-District Level (Tuberculosis Unit Level)
Integrating the TB control programme with the health
system increases effectivenes and efficiency of TB care and
control. India's TB control programme has been
mainstreamed efficiently with National Health Mission
(NHM).
A major organizational change in NTEP is the creation of
a sub-district level (Tuberculosis Unit-TU). TheTU is the
TUS
nodal point for TB control activities in the sub-district.
are based mainly in NHM health blocks with the overal al
to align with NHM Block Programme Management u
(BPMU) for optimum resource utilization and appropria

.
baseu
monitoring. In urban areas the TUs have been created
Intermediate Reference 1.5-2.5 lak
State TB Cell on a population of 1 per 2,00,000 (range
Laboratories (29) 1 per 1,00,000
37 states /UTs tor rural and urban population and areas.
State TB Training and
.26 lakh) population in hilly/tribal/difficult
Demonstration Tuberculosis Unit (TU) consists of a: designated Met
Centre (26)
Officer Tuberculosis Control (MO-TC), as'well as onee
District TB Centre
Culture and DST 767 Districts
time supervisory staff - Senior Treatment SupervIsor
Laboratories (42)
iowever, One Senior TB Laboratory Supervisor (SIL
Nodal DR-TB TB Unit continue to be in 5 lakh population (one pe ision
Centre (154) One per 1.5-2.5 lakh population population for tribal/hilly/difficult areas). There is a
CBNAAT of additional STS if more than 300 TB cases arereghan more, tha
Laboratories (1180) public sector annually in a TU; ditional STS if
Designated Microscopy Centre
50,000 to 1 Lakh population 50 private health establishments are registerea from
in a TU and more than 200 TB patients
are notie
these private health establishments annually, in a edical
Peripheral Health Institute
The Block Medical Officer also functions a
as
Officer TB Control (MO-TC). For the urban ocated
FIG 2 medical officer from the health facility where DHOo
Organization structure of NTEP should be designated, in coordinat with CM&HODNTEP
Source: (17) Tunction as a MO-TC. All MO:TCs should be trained
 wwwwww
479
laberatory
functions of IRls are monitaring of its quality
instilution. MOTC has the overall The nain it
state level and maintenance
of 1B Control Programme at $ervices across the state assurance. There are 27 [Ris
Bnibility of managemeni
esponsi to ndertake supervisary visits for through external guality & DST using Phenotypie (5olid
expected culture
the TU
and is ol STS and STLS are with facilities for and (ernatypic
in a onth. The team Liquid Culture MGIT)
sevEn daysadministrative supervision ol the MO-TC and the &
the for every fechnology (LPA & CBNAATI.
TU will have one Microscopy Centre
The population
DTO. (50,0 in iribal, desert, remote and
ppu 100,000
as the Designated Microscopy CBNAAT sites
DST laboratories.
CBNAAT
Lllu regions) reterred to addition to the culture Rifampicin
complete geographic coverage In
to diagnose
entic (DMC. however, 1or expand sputum smear centresare also established DST}. Usualiy
National programme envisages 1oMicroscopy Centres may patients (Universal
resistance among ail TB DTCs. TB units and medicai
eraict
PHC level).
microscoPy service af
established beyond population
norms in Medical these are established inis in the process of expanding
Jrug
tks also be
hospitals, ESIC, railways, NGOs, private colleges. The country also serve to
diagnose TB
colleges, corporate CBNAAT site network. They
hospitals, etc. from key population
sbes.; among presumptive TB cases
Peripheral Health
Institutions (PHIs)
alion. facility which DRTB Centres (17) clinicai
For the purpose
of NTEP, a PHl is a health level, there specialized centres for
medical officer. At this DRTB Centres are state/regionaldivision
manned by at least a TB. At
is referral hospitals, major management of drug resistantCentres ({NDRTBC). to manage
dispensaries, PlHCs, CHCs, level, there are Nodal
DRTB
are or hospitals (including other DRTB with extensive resistance
and
hospitals. speciality clinics medical seriously ill DRTB cases, vwith regimes containing new drugs
JthCilz hospitals, ART Centres and
health facilities), TB facilities in DRTB cases to be treated
DMO:CR district. All health
colleges within the respective in NTEP are also (Bedaquiline and Delamanid)
disticts sectors participating
and NGO are district DRTB
centres
the private programme. Some of these PHIs At the district level. there cases with MDRTB, and H
actra considered as PHls by the institution DRTB
DMCs. Peripheral health (DDRTBC), to manage the
also function as treatment activities resistance. These centres wili function under
ities in
a undertake tuberculosis
case-finding and where
mono/poly
health services. In situations guidance of NDRTBCs. National
as a part of the general
DTC
in any of the peripheral health there are six designated National
respoisite
more than one MO is posted C. At the central level namely
may be identified and entrusted with Reference Laboratories (NRLs National institute for
itoring &
centres, one of them Visitor
NTEP There is 1 TB Health Tuberculosis Institute, Bengaluru,
ertecxe the responsibilities of the support the urban (NIRT), Chennai. National
(TBHV) per one lakh urban
population to Research in Tuberculosis Diseases
and Respiratory
DTC

TBcontrol activities (17). Institute of Tuberculosis JALMA institute. Agra,

(NITRD), Delhi. National Bhubaneshwar and
Centre,
TB laboratory services
(17) Regional Medical Research Research Centre (BMHRC),
&
are utilized for
diagnosing Bhopal Memorial Hospital is also a Supra National
the hee The services of the laboratory treatment of these Bhopal. NIRT Chennai
TB & DR-TB cases and for
monitoring of Worid Health Organization
TB care
network under NTEP is a 3-tier Reference Lab (SNRL) for Region. NTI i a WHO
has e patients. The laboratory
of diagnostic services
and maintaining (WHO) for the South East Asia
while NITRD is WHO
lth Miss System for provision collaborating centre for training. NRL3
laboratory servces. The
its quality.
situated in the public centre of excellence in TB external quality assurarce of
peripheral laboratories are PHCs, CHCs, referral tor
A. The are mainly responsible resistance surveiliance, waining and
sector like the dispensaries, sector Lab network, drug
eTUst nospitals, major hospitals,
specialty clinics/other the research.
distria colleges and in
overal a hospitals/TB hospitals/medical microscopy
private/NGO sectors. For
establishment of
NTEP endorsed TB
diagnostics (1}
ementU
apprapree
centre in a lab, it must have adequate
a
physical
trained Li.
bacilli.
Smear microscopy for acid
fast
and 1.
Zeihl-Neelsen staining; or
bes& rastructure, Binoculer microscope quality assurance
a. Sputum smear
stained with
laboratories are covered under
realed
nese and examined under direct or
b. Fluoresence stains with or without LED
mechanisms s]putum
having facllity for cenires, indirect microscopy
leas
Medie2 .Some of the labs not sputum collection
nicroscopy, function as a established in areas such asS 2. Culture
Wed Jansen} media; or
i
one such facilities are also difficult to reach areas of a. Solid (Lowenstein
as (S/3 CA nd tribal, hilly, desert and {Micddle Brook) using manual semi
ine access fo diagnostic b. Liquid media e.g., Bactec, MGIT
VISOr
ne country for improving the automatic or automatic machines,
ST BiR Services.
2.5
verprove medical colleges have etc.
addition, large hospitals and rapid molecular test molecular test
Isa
EIsere
n es of digital X-Ray, test
acid amplification Needle
3. Rapid diagnostic
Conventional PCR based Line Probe Assay
for MTB
iartridge based nucleic Assay-LPA), Fine a,
oe BNAAT & Line Probe
(FNAC), histopathology,
and complex; or
based Nucieic Acid Amplification Test
piration Cytology ol TB b. Real-time PCR complex, e.g. GeneXpert.
oed services NAAT for MTB
Culture & DST for diagnostic as
is designated Radiography where available.
a10 nodal laboratory
e state level a laboratory (IRL) which
reference
is usuay
Demonslration
4
Tuberculin skin test.
Un mediate in the State TB
Training and 5
TB
ted
re(STDC)/medical college/public health laboratory.
BHO
480 HEALTH PROGRAMMES IN INDIA
New Initiatives
1. NIKSHAY: TB surveillance using case based web
based IT system (18)
Central TB Division in collaboration with National
Informatics Centre has undertaken the initiative to develop a
case based web based application named Nikshay. The word
is combination of two Hindi words NI and KSHAY, meaning
eradication of TB.
This software was launched in May 2012 and has
following functional components.
Master management
User details
TB patient registration and details of diagnosis, DOT
provider, HIV status, follow-up, contact tracing, outcomes.
Details of solid and liquid culture and DST, LPA,
CBNAAT details.
DR-TB patient registration with details.
Referral and transfer of patients.
Private health facility registration and TB notification.
Mobile application for TB notification.
SMS alerts to patients on registration.
SMS alerts to programme officers.
Automated periodic reports:
a. Case finding
b. Sputum conversion
C. Treatment outcome.
The programme has started using IT enabled adherence
tools like 99 DOTS for HIV-TB patients. This will be
expanded to all TB patients with implementation of daily
regimen (7)
2 TB Notification
n order to ensure proper diagnosis and management of
TBcases, and toMDRreduce TB transmissionand the emergernce
and spread of TB,it is essential to have complete
information of all TB cases. According to the Government of
it is now mandatory
hIndia nötification:dated 7th toMay 2012,every TB case to local
for all healthcare providers notify
authorities i.e District Health Officer/Chief Medical Officer
of a district and Municipal health officer, every month in a
given format (19).
3 Ban on TB Serology i
The serological tests are based on antibody response,
which is highly variable in TB and may reflect remote
infection rather than active disease. Currently available
serological tests are having poor speciticity and should not
be used for the diagnosis of pulmonary or extra-pulmonary
TB. Their import, manufacturing, sale, distribution and use
is banned by the Government of India (18)
4. Direct benefit transfer schemes
Direct beneficiary transfer systems are being established
by linking TB patients reported in
NI SHAY with AADHAR
and PEMS to effectively deliver benefits to TB patients and
their providers (7).
Initiation of treatment
Early identilication of people with high probability of
having active TB (presumptive TB) is the
most important
activity of the case finding strategy. Patients presenting
themselves with symptoms suspicious of tuberculosis
screened through 2 sputum smear examinatiöns. Sputure
microscopic examination is done in designated RNT
microscopy centres. They are located either in the CH
PHC, Taluka Hospitals or in the TB dispensary.Each centre
has a skilled technician to ensure quality control, asenior T
laboratory supervisor is appointed for every 5 microscon
centres. The senior TB laboratory supervisor rechecksall the
positive slides and 10 per cent of the negative slides of thero
five microscopy centres. Thus the error: in diagnosina a
patient is minimized. It is essential to examine 2 sputum
specimens of each patient before a conclusive diagnosis can
be made. One sputum sample is not sufficient for diagnogs
as the chance of detecting smear positive case is only 80 per
cent. Sputum microscopy not only contirms the diagnosis.
but also indicates the degree of infectivity and response to
treatment. ig. 1 on page number shows the critería of
diagnosis and initiation of treatment.
All patients are provided short-course chemotherapy free
of charge. During the intensive phase of.chemotherapy all
the drugs are administered under direct supervision.called
Direct Observed Therapy Short-term (DOTS). DOTS is a
community based tuberculosis treatment and care strategy
which combines the benefits of supervised treatment, and
the benefits of community based care and support. ensures
high cure rates through its three components: appropriate
t
medical treatment, supervision and motivation by a health or
non-health worker, and monitoring of disease status by the
health services. DOTS is given by peripheral health staff such
as MPWs, or through voluntary workers such as teachers,
anganwadi workers, dais, ex-patients, social workers etc
They are known as DOT 'Agent' and paid incentive'
honorarium of Rs 150 per patient completing the treatment
Newer initiatives (11)
1. Daily regimen for paediatric TB: In order to transition
the country to the updated guidelines for paediatrie
treatment in the STCI, which follow the current WHO
dosing guidelines, the government has decided
to
introduce a daily dosing regimen using child-trienuyot
fixed dosage combinations (FDCs). The procurement
anti-TB drugs in daily fixed dose combination (FDG) has
been initiated. Treatment with FDCs of antiTbdrugs
w
be in six weight bands for paediatric patients An optio
family members to provide. Directly 0bservec
forTreatment (DOT) to paediatric patients has been
incorporated in the guidelines.
2 Daily regimen for all forms of TB in the country.
3. Pilots for universal access to TB cases.
4 Universal drug susceptibility testing (DST)pa0 up
rapid molecular diagnostics have been scaled too
decentralized
CBNAAT, covering all districts for
5op
diagnosis of drug resistant TB services: Nearlyuniversal aru
cent ot all notified TB cases were offered
SUSceptibility testing in 3rd quarter of 2019.
5 Shorter regimen and Bedaquiline In 2018 snot
egimen and Bedaquiline for treatment otcountryrro
air From
expanded in the
Bpatients, have been
2018, more than 46,129 DR-TB patients haves
initiated on shorter regimen and 7,973 DRBpe
on newer drug containing regimen.
reaco he
: Campaign mode -Active case findingTo syste
unreached, the programme has carried out
populations thtol
active TB screening among high risk lation,
house visits or targeted setting visit (tribal poP
 , slums, old age homes prisons, orphanages,
MANAGEMENT OF DRUG RESISTANT TB
481
etc.) The ampaign was conducted in transit camps
e priority districts
d based on burden of TB, case finding bedded tertiary care facility established to serve a population
of approximately 10 million, with an airborne infection control
TR and drug resistant TB in efforts, HIV
the respective districts (7). compliant ward, facilities for pretreatment evaluations,
treatment initiations, follow-up monitoring and management
The drugs are supplied in patient-wise boxes of adverse drug reactions, prevention and relief of physical and
the sll course of treatment, and packaged in blister
containing
r the intensive phase, each blister pack
medication. For the continuation
packs.
contains one day's
social suffering caused by the disease and its treatment,
complications and co-morbidities. All these activities are
phase,
ntains one weeks supply of medication.each blister pack supported by the programme staff in addition to having
counselling for patients and undertaking data management.
The combipack
icion drugs for extension or intensive phase are supplied By 2017, 147 DR-TBCs were established across India,
ase'is
separately. bOxes are coloured according to
heregimen, designated as Nodal DR-TB centre, one for approximately
eategory of the red for category I
the
oty patients, blue for every 10 million population, including some in private
category ll patients.
yand"estyr nstitutes partnering with RNTCP About 5 to 10 districts are
Orsîhe. Paediatric tuberculosis attached to each centre. DR-TB patients are admitted for a
cit short period and once stabilized on treatment, discharged
Please refer to page 218 for details. with advance intimation to the districts and referred back to
chenohep their districts for continuation and completion of treatment.
chemoteeA Drug resistance surveillance (DRS) under During treatment they are referred back to DR-TBCs for
NTEP (2014-2016) (16) change of regimens and management of adverse reactions.
OTS). The prevalence of drug resistance to TB can be taken To decentralize the pretreatment evaluation, treatment
DUTS as
andcaxesoxon an indicator of the effectiveness of the TB control initiation of RR.TB or H mono/poly DR-TB and follow-up
activities
over a period of time and, therefore, RNTCP has taken steps processes, two distinct types of DR-TBCs will be established.
edteatmet,
suppont to measure this important indicator. The existing nodal DR-TB centre (NDR-TBC) will continue
nents:
tesa The aim of DRS is to determine the prevalence of for approximately 10 million population. One District DR-TB
apprsz4
ationboy antimycobacterial drug resistance among new sputum smear centre (DDR-TBC) will be established for every district.
positive pulmonary tuberculosis (PTB) patients, and also Some of the states have already established these centres.
zal health
amongst previously treated sputum smear positive PTB The advantages of decentralized "test and treat
sadse
patients. Drug-resistant TB has frequently been encountered approach" are (20):
such taca
&6
in India, and its presence has been known virtually from the Early and faster initiation of treatment of all diagnosed
ocial uodhes
time anti-TB drugs were introduced for the treatment of TB. DR-TB patients;
d paid inesa
To obtain a more precise estimate of Multi-Drug Resistant Bringing care closer to the residence of majority of the
ing the terxr TB (MDR-TB) burden in the country, RNTCP carried out DR-TB patients;
drug resistance surveillance (DRS) surveys (2014-2016) in Significant reduction in catastrophic expenditure
accordance with global guidelines in selected states. The including loss of work hours and family income;
order to tresi results of these surveys indicate prevalence of MDR-TB to be Rationally minimizing the need and duration for
es for puae* about 2.84 per cent in new cases and 11.60 per cent in hospitalization;
the curett
K retreatment cases (17) Minimizing travel of patients, thereby transmission risks
derde
has during travels;
chil:es
ngprocuenett MANAGEMENT OF DRUG RESISTANT TB Accountability of the district programme management
e The services for quality diagnosis units; and
and treatment of drug
ination jA resistant TB cases were initiated in 2007 in Gujarat and Rationalizing utilization of existing DR-TBCs to enable
ant-lbcas Maharashtra. These services since then have been scaled up them to concentrate in more complex clinical decisions
afienis.At g ànd currently these services are available across the and ensuring quality assurance of treatment and
Ciere research.
rectly COuntry from March 2013. For full details about the patient
enis
has ke regimens, please refer to page 219.
1. District DR-TB centre (20)
State-level structure and responsibilities (20) The DDR-TBC is responsible for the initiation and
Couniy
While a national expert technical working group has management of uncomplicated DR-TB patients like RR-TB
developed national policies, technical and operational or H mono/poly DR-TB in a district, not only on inpatient
Ezpanst
guidelines, the state-level is where the majority of planning basis, but also on outpatient basis, wherever advisable and
ac state possible. The DDR-TBC can be established at institutes in a
decentalat
S, implementation and monitoring occur.theThe plan of certain order of preference, namely, medical colleges, district
is responsible for developing
Neanfy P Committee
action for implementation, expansion, maintenance, hospitals, TB hospitals and NGO/private/corporate
institutes/other sector hospitals with the availability of
ervision, monitoring and quality enhancement of PMD
Services in the respective state. required clinical expertise.
2. Nodal DR-TB centre (20)
Drug-resistant tuberculosis centre (20
drg 1S Patients with additional resistance to second-line drugs,
of
e,.counui ogrammatic and clinical management of DR-TB to drug intolerance, contraindications, failing regimen, patients
eftex but feasible when the health system is strengthened returning after treatment interruption of>1 month,
DRIB p eltectively integrate
what is necessary onttalized and emergence of any exclusion criteria for standard regimen for
resistant TB is not completely
oas on In fact, clinica RR-TB or H mono/poly DR-TBB regimen, non-TB
care for the entire duration. n
clinical
Care ndized support expert mycobacterium (NTMs) and those needing palliative care
Tesourea e presence of a clinical and patient would be managed at NDR-TBC.
is a 20-30
centre. This is the DR-TB Centre, which
 HEALTH PROGRAMMES IN INDIA
The requirements for the NDR-TB centre are as follows: care service delivery in India. As per National Sar
Should preferably be a tertiary care institute; Survey Organization report, about 70 per cent patientee
care in private clinics and hospitals (21). Seek
Separate ward for male and female patients should be
available with at least 10 beds in each; Delays in diagnosis, over-diagnosis of TB due to
an.
All PMDT services (beds, investigations, ECG and dependence on X-rays, the use of multiple non-stanOver.
ancillary drugs for management of adverse dru1g
a
regimens for inappropriate durations, the lack of mechaud
reactions) to be provided free of cost to the patient; to ensure full course ot treatment and to record tro
outcomes are some issues ot concernin the private s
Relevant specialties including respiratory medicine, te sector.
genera medicine, psychiatry, dermatology, ENT, Similar problems in varying degrees are encountered in other
health sectors as well. The advantages and disadvantages od
ophthalmology, gynaecology, paediatrician, public and private sector are as shown below:
anaesthesiologist and cardiologist should be available
directly or through linkages; Public sector Private sector
NDR-TBC committee to be formed;
National training of NDR-TBC committee members Advantages Free diagnosis .Wide choices (> 5
(including Chairperson); Free treatment lakh practitioners)
Standardized regimenBetter access
National AIC guidelines to be implemented in DR-TB Referral and transfer -
Convenient timing5
wards and outpatients setting. system Shorter distances
Routine clinical laboratory investigation facility to be Supervision and Personal attention
monitoring andcare
made available for pretreatment evaluation and Accountability of Projected discounts
monitoring: treatment outcome Faith and perceptions
Ancillary drugs should be available; of better care
Management of adverse drug reaction as per PMDT Disadvantages Staff's non-response Cost of clinical
guidelines;
Doctors, nursing and support staff should be available
tosymptomns
between tests
examination fees
Cost of diagnostic
S T, Delays tests
from the institute; and receiving
Reports and records to be maintained for PMDT; and results Cost ofdrugs
3 Difficulty in Irrational
Quarterly report to be submitted electronically. transporting prescriptions
Infrequent use of
The overall structure and roles of different level of PMDT T 7 : specimens
Financial expenditure quality sputum tests
services are summarized in Fig. 3. 23 I tor diagnosis of TB
on travel, food, daily
adherence
TB care services in the private sector necessities, extra No
tracking mechanisms
medicines patient
The private sector is everything outside the ambit of the Perceived low quality Fear of losing RNTCP
if involved in
Government run public health services. It varies widely in its of services
size, nature of service delivery and the socio-economic
groups served. It holds a factual predominance of health Source: (21)

lab Nodal DR-TBC State drug store

C&DST
to distr
Maintain ward & AlC measures Prepare & ship drug boxes
Receive Dx/FU specimens Pre-treatment evaluation level
Provide rapid results to district, Manage supply chain for
Field and DR TB centre Start M/XDR TB treatment
diagnostics and drug9s
Maintain records & NIKSHAY Consult for complications NIKSHAY &
Quality assurance of results Clinical expert resource Maintain records,
DVDMS
Maintain records & NIKSHAY

District DR-TBC District

CBNAAT lab
specimens
Diagnose RR-TB patients at
district Initiate patient on standard DR-TB ldentify suspects, refer
results
level
regimen (MDR/RR-TB, Coordinate for test
N/DDR-TBC
NIKSHAY Hmono/poly DR-TB patients) Refer patients to
Maintain records & Manage ADR & drug flow
irou
Coordinate care to field level
Maintain records and NIKSHAY district drug storeNIKSHAY,
Maintain records,
monitor & supervise
Field

Identify presumptive case, refer specimens Manage minor adverse effects

Support, supervise, manage
DR-TB patients Refer patient for the treatment initiation
Communicate results to patients Collect and refer follow-up specimens

3
Overall PMDT structure and role

Source: (20)
 MANAGEMENT OF DRUG RESISTANT TB 483
strategicvision of RNTCP is to lay down guidelines
in country. The underlying principle The National AlDS Control Programme (NACP) and
rms for TB care RNICP have taken the policy decision to adopt isoniazia
to extend blic services to privately managed prophylaxis therapy (1PT) as a strategy for prevention ot
s. Standar tor TB care in India, mandatory TB
NIKSHAY, ban on serodiagnostics are among Bamong PLHIV. The implementation will be in a
tio phased manner.
improve TB care services in private sector.
ls to 8. The RNTCP has prioritized presumptive TB cases among
ools, however, are limited and partnership is
tory
Programme staff:should understand that RNTCP people living with HIV for diagnosis of TB and
Rifampicin resistance with rapid diagnostic tools having
arvate providers more than private providers need high sensitivity e.g. Xpert MTB/RIE
TCR detail on
The treatment guidelines are discussed in
IV coordination (22) page 231.
-o
the advent of the
collaborative efforts in 2001 Tuberculosis in pregnancy
activities have evolved to cover most of the
Please refer to page 225 for details.
mendations as per the latest WHO policy statement Elimination
in2012. In 2007, the first national framework
for joint National Strategic Plan (2017-2025) for TB
collaborative activities was developed which 2017-2025 for TB
the heterogeneity The National Strategic Plan (NSP) NSP. It is a three
ed a differential strategy reflective of of last
elimination builds on the success
HIV epidemic. Coordinated TB-HIV
interventions were strategic document.It
of a coordinating body year costed plan and an eight year country's response to
nented including establishment the
provides goals and strategies for2017-2025
resources, to bring about
ional and state level, dedicated human the disease during the period
prevalence and
monitoring and evaluation, incidence,
ation of surveillance, joint SIgnificant changes in the global End TB targets five
ty building and
operational research. the
mortality of TB, and attain Development Goal of TB free
TB/HIV activities of Sustainable
implementation of collaborative years ahead free India with zero
deaths,
India. The VISION is TB
TB (23).
follows:
been implemented disease and poverty due to
ensified TB case finding has centres (known as
tionwide at all HIV testing 1CTCs), Objectives:
testing centres, or NPS are:
egrated counselling and centres. The main objectives of TB cases
d has now been extended
to all ART TB and drug resistant
is now routine through provider 1. Find all drug sensitivereaching TB patients seeking care
V testing of TB patients on
implemented in with an emphasis TB in high-risk
counselling (PITC), providers, and undiagnosed
tiated testing and TB-HIV package. from private
states with the intensified eligible for free HlIv populations. appropriate anti-TB
are
to be HIV-positivetreatment (ART) centres. all patients on
TSons found 2. Initiate and sustain seek care, with patient friendly
Te
antiretrovial
at a network of colleges, mainly treatment wherever they
in medical support.
centres are located societies, systems and social populations.
by the state AIDS control
or emergence of TB in susceptible empowered
operated private Prevent the
the facilities of
afted and 3. policies,
few are situated within there were strengthen enabling with enhanced
dapartners. As of December 2017,1120 4. Build and human resources
J0 country,
link-ART institutions, additional adequate financial resources.
operating in the Regional capacities, and provide
0 ARI centres link-ART plus centres. Ten follows:
Tntres and 158
provide second-line ART services The key
strategies are as
Excellence line ART (ART engagement
2ntres of
24 centres provide second who are on 1. Private sector
PLHIV, and
HIV-infected TB patients getting Active case finding management
IS centres).
second line ART are 2.
Drug resistant
TB case nutrition
orease inhibitor based Ritampicin. 3. determinants including
place of Addressing social system
doutin-based TB treatment in National Technical 4. surveillance multi-sectoral approach
taken by
Icy decision has
been collaborative activities 5. Robust engagement and
TB/HIV blood Community
OTking Group on
expand coverage of whole without a 6.
on TB/HIV) to DMC
WG HIV screening test at all Expected outcome:National Strategic Plan achieve
is to
targets for
prick the period,
and-alone or F-ICTC counselling (PI a The aim ofTB by 2025. During plan
testing and now elimination of
OVIder initiated HIV (TB suspects) is reduction from 211
presumptive TB cases TB are: TB incidence (i.e.
Ihe reduction in
olicy states/settings manne, 1. 80% lakh) from 32
to 43 per (i.e. reduction
HIV. prevalent phased lakh
per reduction in TB
mortality
high be done in aand then in A and
will
plementation prevalent states 2. 90%lakh to 3 per lakh expenditure due to TB
per catastrophic interventions are
Starting with high HIV testing
rest of the
B category districts in states/settings
HIV outinely patient having
3. 0% comprehensively
deployed incidence of TB
ld be decline of requirements of
In low HlV prevalent s in low New accelerate the rate of
presumptive TB cases 25-54 years there The
required to 10-15 per cent annually. been integrated into
nong age-group of places where than elimination have
Detect-Ireat-Prevent-Build (DTPB).
the
remented indistricts D) at facilities. to more
(C &testing specifically towards TB
HIV prevalent moving of
HIV strategic pillars
CO-located TB and activities to be women and four
ng pregnant
among HIV infected
dren living with HIv.
 496 HEALTH PROGRAMMES IN INDIA
delivery from PH to Suo-centre and outreac
and to achieve self-sufficiency in the production of (b) Deploying retired manpower to carry out i m sessio
Programme was started in underserved dniza
vaccines. Universal Immunization activities in urban slums and support whe
It has two vital components: immunization of
India in 1985.
immunization o services are deficient, (C) Mobility
pregnant women against tetanus, and the six EPT
immunization officer as per state plan for monitdIstie
thing an
against
children in their first year of life
supportive supervision; (a) Keview meeting at
target diseases. Ihe aim was to achieve 100
per cent
with the districts at o montny ntervals, (e) Training ove
of pregnant women with 2 doses of tetanus toxO1d
handlers, mid-level managers, rofANM
COverage
or cold chain
per cent cOverage
at
mechanics etc.; (1) Support for mobilization
dose), and least 85
(or a booster dose of BC
of children
women self-help
intants with 3 doses each of DPT, OPV, one immunization session sites by ASHA,
and one dose of measles vaccine by 1990. Universal etc.; (g) Printing of immunization cards, monitorinep sheet
immunization was tirst taken up in 30 selected districts and cold chain chart vaccine inventory charts etc.
catchment areas of 50 Medical Colleges in November 1985. In addition, central government is Supporting in
sun
The programme now covers entire country and pracice
of auto-disable syringes, downsizing the
BCG vial fplles
areas of all the 242 Medical colleges, thus creating a base tor
ensure that BCG vaccine is aom 20

wider coverage (39). A "Technology Mission on Vaccinatiopn doses to 10 doses to

specialy all immunization session Sites, strengthening
and Immunization of Vulnerable Population, system in the stata. and
Children was set up to cover all aspects of the immunization maintenance of the cold chainvan. and
delivery O supply ot vaccines and vacCine
activity from research and development to actual
services to the target population (40). PULSE POLIO IMMUNIZATION PROGRAMME
through the
Ihe immunization services are being provided Pulse Polio Immunization Programme was launched in tha
system (i.e., MCH centres,
exIsting health care delivery country in the year 1995. Under this programme childrer
primary health centres and subcentres, hospitals, dispensaries
Ihe under five years of age are given additional oral polio drop
and ICD units). There is no separate cadre of staft for EPI. in December and January every year on ftixed days, Fr
immunization schedule is on page 134.
recommended 1999-2000, house to housevaccination of missed childre
by
Although the target was "universal" immunization was also introduced. The NILDs rounds cover approximatel
in the industrialized 172 million children and SNIDS rounds cover 40-80 millic
T990, in practice, no country, even
world, has ever achieved 100 per cent immunization in children. In addition, large scale multi-district mop-ups hau
children. Universal immunization is, theretore, best been conducted (42). As a result only one case of polio
w

that no child should be reported in 2011 in the month of danuary. As on 25th F

interpreted as implying the ideal diphtheria,
denied immunization against tuberculosis, 2012, India was removed from the list of polio endem
It is, however,
whooping cough, tetanus, polio and measles. countries, and on 27th March 2014, India was certified
coverage
generally agreed that when immunization polio-free country. Please see page 242 for more details.
reaches a figure of 80 per cent or more, then disease
as to provide INTRODUCTION OF INACTIVATED POLIO VACCI
transmission patterns are so severely disrupted
a degree of protection even for the remaining children who (IPV)
of "herd immunity
have not been immunized, because are immunized during The last global case due to wPV type-2 was reportea
41). It is also important that children Aligarh in India in 1999. Most of the global cases due
the first year of life and that levels of immunization are VDPVs (97%) as well as VAPP (40%) are due to type-2 vi

Sustained so that each new generation is protected.
Significant achievements have been made in India. At the
beginning of the programme in 1985-86, vaccine coverage toor
ranged between 29 per cent for BCG and 41 per cent
DPT. By the end of 2018, coverage levels had gone up
signiticantly to about 90 per cent for tetanus toxoid for
pregnant women, about 92 per cent for BCG, 89 per cent for
This necessitates the discontinuation of the use of
ty
component from OPV. Polio Endgame Strategic Plan
recommends replacing tOPV with bOPV. However, thisV
the recent birth cohort at the time of switch at risk
of
and wild polio virus type 2 due to silent/ongoing transma
of VDPV type-2 and also to potential leakage of wild
virus type-2 in case of accidental/intended leakage
o

DPT 3 doses, 89 per cent for OPV 3 doses, 89 per cent for virus froma laboratory. To mitigate this risk, inactivated
HepB,, 89 per cent for Hib, and 80 per cent for MCV2. Since virus vaccine was introduced prior to the tOPV-bOPV:
then, there is a signiticant decline in the reported incidence in April 2016. As part of this Polio Endgame Strategy.
of the vaccine preventable diseases as compared to their
(1PV)
has introduced Inactivated Polio Vaccine
incidence in 1987, as shown in Table 9. 30 November 2015. It is given as fractional IPV of 0.ln
as intradermal injection at 6 and 14 weeks of lite (6).
TABLE 9
Decline in reported vaccine preventable INTRODUCTION OF MEASLES VACCINE SEC
diseases trom year 1987 to 2018 OPPORTUNITY
Disease 1987 2018 In order to accelerate the reduction of measles
morbidity and mortality, second opportunity tor
Poliomyelitis 28,257
11,720
vaccination is being implemented. The National l
Diphtheria 12,952 Advisory Group on immunization recommended intre
Pertussis 163,786 18,006 of 2nd dose of measles vaccine to children between
NNT 11,849 181 and 10 years of age through supplementary imm
247,519 20,815 activity (SIA) for states where evaluated coverage o
Measles sta
of measles vaccination is less than 80 per cent. In
To strengthen routine immunization, Government of India coverage ot measles vaccination more than 80 per
has planned the State Programme Implementation Plan (PIP) second dose of vaccine will be given throug
part C. It consists of: (a) Support for alternate vaccine immunization at 16-24 months (1).
 UNIVERSAL IMMUNIZATION PROGRAMME
497
CTION OF PENTAVALENT VACCINE involves intensive preparatio
+ Hib) nOct2017. and It
integration of sessions into reguta
Hep B piementation is an urban siu are
alent vacCine contains five antigens i.e., nmunization microplans. The focus
pertusis, tetanus and haemophil a aistricts with slowest progress and completion of due
phtheria, surveys. AS On
B.
vaccine. Pentavalent vaccine is giv OT Deneticiaries on the basis of head count
b (Hib) at were 49.0 1a
14th weeks as primary aose. I he vaccine has dan, Z018, number of children vaccinated
number of children fully vaccinated was 12.0Z 1akn
orhepatitisB vaccines in the immunization 77
(

d DP
However, birth
birth dose of hepatitis B and two umoer of pregnant women vaccinated was 10.05 lakn
le.
ses DPT will continue as before (6).
r doses of MEASLES-RUBELLA (MR) VACCINE
India introduced pentavalent vaccine in two elimination
ally WHO regional goal for SEAR is measles
- Kerala and Tamil Nadu. Presently it covers the he
ana rubella/congenital rubella syndrome control by z040.
country.
ne M vaccine is being introduced through campaig
onUCTION OF JAPANESE ENCEPHALITIS argeting around 41 crore children in the age group, o
months to 15 years in phased manner (covering l/STd o
in
population of the country), followed by 2 doses
CINE

amme was introduced in 2006 to cover 104 eOta

districts in phased manner, using SA 14-14-2 vaccine,
China. Single dose of JEvaccine was given to all
rted tror
en between I to 15 years or age through campaigns (3).
in
Evaccine is being integrated into routine immunization
istricts where campaign nad already been conducted to
anize
the new cohort of children by vaccinating with two
sat 9-12 months and 16-24 months (1).
high burden districts have been identified in Assam,
Pradesh and West Bengal for adult JE vaccination in
ge group of 15-65 years. This will cut down deaths and
bidity due to JE in adults as well (6).
RODUCTION OF ROTA VIRUS VACCINE
Rota
virus vaccine was introduced in 2016 in Odisha,
achal Pradesh, Haryana and Andhra Pradesh, and later
will be expanded to the whole country. It will be given
ler universal immunization programme as
a
cine along with pentavalent 1st, 2nd and 3rd dose (6).
3 dose
"BELLA VACCINE
To (MR) campaign
be initiated as Measles Rubella
geting 9 months to 15 years of age in a phased manner
er a
period of three years. Subsequently, the Rubella
cine will be introduced as MR vaccine as two doses in the
ice ot measles containing vaccine 1 and 2 at 9-12 months
d
lb-24 months as per NTAGI recommendations (6)
ISSION INDRADHANUSH
Ihe Ministry of Health && Family Welfare has launched
0n Indradhanush", depicting seven colours of tne
O, in December 2014, to fully immunize 9u per cent
aren who are either unvaccinated or partialy
eathose that have not been covered during the
020 TTOutine immunization for various reasons, by
.Ihe target has now been pre-poned to Z018 (/).
ton Indradhanush has completed six pnases
20pril 2015 to Dec. 2018) covering 681 districts wnerein
meChildren were reached; 81.79 lakh children were
nunized;
nmunized.
and 87.18 lakh pregnant women were
aveled The first two phases of Mission Indradhanush
t
overaaean increase of 6.7 per cent in full immunization
TOutine immunization at 9-12 months and 16-24 montns,
replacing the measles vaccine (7).
2017 from
MR campaign was launched in February Lakshadweep and
States/UTs (Karnataka, Tamil Nadu, Goa,
Puducherry) where 3.34 crore children were vaccinated
against the target of 3.43 crore, with a coverage of 97 per cent.
ampaign has completed 33 states and immunized
32.36 crore children (97.04 per cent of the target) (11).
PNEUMOCOCCAL VACCINE (PCV)
PCV was launched in May 2017 for reducing infant
mortality and morbidity caused by pneumococcal pneumonia.
he vaccine has been introduced in Himachal Pradesh,
6 districts of Uttar Pradesh and 17 districts of Bihar
Madhya Pradesh, and Haryana. Till September 2019, around
192.49 lakh children were vaccinated (11).
Very frequently queries come up about the vaccines and
the vaccination schedule. It is important to have the exact
answer to these questions.
Questions about all vaccines (43)
Q. If the mother/caregiver permits administration of only
one injection during an intant's first visit at 9 months of
age, which vaccine should be given ?
A. At 9 months of age, the priority is to give measles
vaccine with OPV and Vitamin-A.
Q. Which vaccines can be given to a child between
1-5 years of age, who has never been vaccinated?
A. The child should be given DPT1, OPV-1, measles
and
2 ml of vitamin A solution. It should then be given the
second and third doses of DPT and OPV at one month
intervals. Measles second dose is also to be given as per the
schedule. The booster dose of OPV/DPT can be given at a
minimum of 6 months after administering OPV3/DPT3.
Q. Which vaccines can be given to a child between
5-7 years ot age, who has never been vaccinated?
A. The child should be given first, second and
third doses ofF
DPT at one month intervals. The booster
dose of DPT
can be given at a minimum ot 6 months
after
administering DPT3 upto 7 years of age.
Q. Should one re-start with the first dose of a
child is brought late for a dose?
vaccine if a

increase e year, as compared to 1 per cent in the past.

was more in
A. Do not start the schedule
all over again even if the chil
compar
as rural areas (7.9 per cent) as
in rur
us of th rban areas (3.1 per cent), hence shifting the
is brought late for a dose. Pick up where the
was left oft. For example: if child who has schedul
programme towards urban areas (l. a
BCG, HepB-1, DPT-1 and OPV-1 at 5 receive
nsified Mission months of age
Indradhan A total of 190 districts/ returns at 11 months of age, vaccinate the
DPT-2, HepB-2, OPV-2 and measles child wit
nlensifiod,across
ihed missi 24 states have been identified where and do not sta
indradhanush has started. It was launched from DPT-1, HepB-l again.
 511
vision for
safe abortion services and blood PRADHAN MANTRI sURAKSHIT MAIKIT V
ansfusion. Terminanon or pregnancy with RU 486 ABHIYAN (PMSMA)
rai Misoprostol is oftered to women under the Abhiyan (PMSMA)
ano
areview of the MTP Act, 1971. The Pradhan Mantri Surakshit Matritva
June, 2016. Under
. fanual Vacuum Aspiration (MVA): The department
family welfare nas introduced Manual Vacuum
Aspiration (MVA) technique in the lamily welfare
nas been launched by the Ministry incountry
MSMA, all pregnant women in the
TIxed day, free of cost assured and
are provided
quality antenatal care. Hs
of antenatal care
part of the campaign, a minimum package being
nrogramme. Manual vacuum Aspiration is a safe and investigations and drugs) is montn.
ncluding beneficiaries
simple technique for termination of early pregnancy, on the 9th day of every
provided to the care
makes it 1easibie oe usea 1n primary health centres
orComparable facilities. thereby increasing access to he Abhiyan also involves private sector s healtn
as volunteers to provide speCialist
care n
providerS
ANC check-ups were
safe abortion services. 1he project of introducing the government facilities. About 2.20 crore
in coordination with more than 17,000
MVA technique has been piloted conducted by about 6,000 volunteers in
FOGSI, WHO and respective state governments government tacilities. Also, more than 11.66
lakh high risk
before being accepted tor implementation by the pregnancy cases were identified across the country (11).
ministry of health and family welfare.
SUMAN (Surakshit Matritva Aashwasan)
Health and Nutrition Day "SUMAN
Village
Ministry has launched a new initiative namely
Organizing Village Health and Nutrition Day once a Surakshit Matritva Aashwasan" on 10th October, 2019 with an
centre to provide antenatal/post- assured, dignified, respectful and quality
month at anganwad aim to provide tor of services
partum care 1or pregnant women, promote institutional healthcare at no cost and zero tolerance denial
health tacility
delivery, health education, immunization, tamily planning or every woman and newborn visiting the public newborn deaths
and nutrition services etc. in order to end all preventable maternal and
and morbidities and provide a positive birthing experience.
Maternal death review is "Zero
The expected outcome of this new initiative
Maternal death review as a strategy has been spelt out preventable maternal and newborn deaths and high quality
clearly in the RCH-11. Maternal death audit, both facility and of maternity care delivered with dignity and respect (11).
community based, is an important strategy to improve the
quality of obstetric care and reduce maternal mortality and LAQSHYA PROGRAMME (11)
morbidity. Guidelines and tools tor initiating maternal deathn MOHFW launched "LaQshya program to improve
review have been formulated (3). quality of care in labour room and maternity Ols in public
health facilities in 2017. The LaQshya programme is
Pregnancy tracking
evidence based approach to imprve quality of maternal
The link between pregnancy-related care and maternal and newborn care and provide respecttul care. particularly
mortality is well established. RCH-II stresses the need for during the intrapartum and postpartum periods, which are
universal SCreening of pregnant women and providingg the most vulnerable periods for a woman and contribute to a
essential and emergency obstetric care. Focussed antenatal significant proportion of maternal deaths.
care, birth preparedness and complication readiness, skilled
Its implementation involves improving infrastructure
arendance at birth, care within the first seven days etc. are upgradation, ensuring availability of essential equipment
the factors that can reduce the maternal mortality (3).
providing adequate human resources, capacity building of
JANANI-SHISHU SURAKSHA KARYAKRAM (JSSK) health care workers, and adherence to clinical guidelines and
improving quality processes in labour room and maternity OT.
Government of India launched the Janani-Shishu LaQshya program is being implemented at District Hospital
Suraksha Karyakram (JSSK) on 1st June 2011, a new (DH), Sub district Hospital (SDH), high case load Community
national initiative, to make available better health facitlies Health Centre (CHC) and First Referral Units (FRUS), and
OT women and child. The new initiatives provide
the medical colleges. 2,445 public health facilities including
O1OWing facilities to the pregnant women (54/. 193 medical colleges have been identified under LaQshya. Out
of these, 441 labour rooms and 39201s have achieved state
Al pregnant women delivering in public health
certification. Natio ication tor Lashya has been
institutions to have absolutely free and no expense
achieved by 152 labour rooms and 127 OTs till October, 2019.
aelivery, including caesarean section. The entitlemenis
ude free drugs and consumables, free diet upto 3 days Regional trainings of trainers have been completed for all
auring normal delivery and upto 7 days for C-section, States/UTs across country to build a critical mass of trainers
aiagnostics, and free blood wherever required. I his who took this training cascade further. State orientation and
would also provide for free transport irom home baseline assessment have been conducted for all State/UTs.
ative
to institution, between facilities in case of a reterral ana Based on the gaps, tne states have prepared gap closure
rop back home. Similar entitlements have been put in plan. Onsite mentoring is being conducted in 24 identified
Place for al sick newborns accessing publichealth medical colleges to accelerate process of certification in
Institu for treatment till 30 days after birth. he medical colleges.Layshya portal has been finalized and
now been extendedto cover the operationalized. Data upload on LaQshya portal has been
has
mplications during ANC, PNC and also sick intants initiated to aid digitization ot all LaQshya related data,
ne scheme is estimated to benefit more than
women who access government health
2 million
tacilities
readily available results and visualization through dashboard.
for ANAEMIA MUKT BHARAT PROGRAMME
sHtheir delivery. Moreover, it will motivate those wno
se to deliver at their homes to opt for To address the problem of malnutrition the focus of
insfit
institutional deliveries. Poshan Abhiyaan on the first 1000 days of the child, which
512 HEALTH PROGRAMMES IN INDIA

includes the nine months of pregnancy, six months of
exclusive breast-feeding and the period from 6 months to
2 years to ensure focussed interventions on addressing
under-nutrition. Besides increasing the birth weight, it will
help to reduce both Infant Mortality Rate (MR) and Maternal
Mortality Rate (MMR). Additional one year of sustained
intervention (till the age of 3 years) would ensure that the
gains of the first 1.000 days are consolidated. Attention is
also given on children in the age group of 3-6 years for their
verall development through the platform of the Anganwadi
Centres (AWCs). One such initiative under the Poshan
Abhiyaan is to promote behaviour change among the
communities and to improve maternal and child nutrition by
organizing community-based events in a structured way (54)
Child health components
The strategy for child health care, aims to reduce under-
five child mortality through interventions at every level of
service delivery and through improved child care practices
and child nutrition.
Nutritional rehabilitation centres (NRCs)
Severe acute malnutrition is an important contributing
factor for most deaths among children suffering from
common childhood illness such as diarrhoea and pneumonia.
Deaths among these malnourished children are preventable,
orovided timely and appropriate actions are taken. NRCs are
acility based units providing medical and nutritional care to
evere Acute Malnutrition (SAM) children under 5 years
ge who have medical complications. In addition special of
cus is on improving the skill of mothers on child care and
eding practices so that the child continues to get adequate
are at home. The services
provided at the NRCs include (1):
24 hours care and monitoring of the child
Treatment of medical complication;
Therapeutic feeding;
Sensory stimulation and emotional care;
Counselling on appropriate feed, care and hygiene;
Demonstration and practice-by-doing on the preparation
of energy dense food using locally available, culturally
acceptable and affordable food items;
Social assessment of the family to identify and address
contributory factors; and
Follow up of the children discharged from
the facility.
Take a history concerning
ecent intake of food and fluids Anthropometry-weight, height/length, mid arm circumference.
sual diet (before the current Oedema.
illness) Pulse, heart rate, respiratory rate.
reastfeeding Signs of dehydration.
uration and frequency of Shock (cold hands, slow capillary refill, weak and rapid pulse).
diarrhoea and vomiting
peof diarrhoea (watery/ Palmar pallor.
Eye signs of vitamin A deficiency:
bloody)
Dry conjunctiva or cornea,
-
Management of medical complicatio
child with SAM at health facility (55 in a
A majority of the deaths in hospitals occur withi
hours of admission, many of these deaths can ho
if the critically ill children are identified
as soon
n
admitted and their treatment is started immediateluthey
Triage
Triage is the process of rapidly screening
sick child-
Triage must be done for all paediatric patients
coming to
health facility. The first step is to check every
emergency signs and provide emergency child
treatment
necessary, keeping in mind the ABCD steps Airu
Breathing, Circulation, Coma, Convulsion and Dehydrati
Assessment at admission (55)
The child should be assessed by taking detailed hist
and should be examined for the signs of under-nutrition
Principles of hospital-based management (55)
The principles of management of SAM are based
phases: stabilization phase, transition phase on
rehabilitative phase. a
Stabilization Phase: Children with SAM without an adequae
appetite and/or a major medical complication are stabilized
an in-patient facility. This phase usually lasts for 1-2 dau
The feeding formula used during this phase is Starter diet whi-
promotes recovery of normal metabolic function and nutiic
-
electrolytic balance. All children must be carefully monitor=
for signs of overfeeding or over hydration in this phase.
Transition Phase: This phase is the subsequent part of t
stabilization phase and usually lasts for 2-3 days. TH
transition phase is intended to ensure that the child
clinically stable and can tolerate an increased energy ar
protein intake. The child moves to the Transition Phasefro
Stabilization Phase when there is:
At least the beginning of loss of oedema.
AND
Return of appetite.
AND
No nasogastric tube, infusions, no severe medical problem
AND
Is
alert and active?
On examination,look for

ronic cough
s -
Bitot's spots
of appetite
Corneal ulceration
nily circumstances (to
nderstand the child's social Keratomalacia
ackground). oniai
Localizing signs of infection, including ear and throat infections, skin infection or pneum0
tact with tuberculosis Mouth ulcers.
ent contact with measiles Skin changes of kwashiorkor:
wn or suspected HIV Hypo or hyperpigmentation
ection Desquamation
unizations Ulceration spreading over limbs, thighs, genitalia, groin, and behind the ears ndidal
Exudative lesions (resembling severe burns) often with secondary infection(includn
 PROGRAMMES IN INDIA
AYUSHMAN BHARAT
PROGRAMM
HEALTH
534
Unusual isolate Govt. of India nound
of cases In February 2018, the sector with aim ttwo
Shifting in age distribution in healtn Cove
vector density major initiativesnealtn promotive interventions
Sudden increase/high preventive and They are as folllmary
as tollows (69
stem. They
care system.
Natural disasters events Tor secondary and tertiary National Heal
syndromes and trigger Wellness Center: The Wellness Centoolicy
Summary of outbreak 1. Health and
Health and
investigation (6/) 2017 has envisioneds health system. Under this 1 the
foundation of India Care system closer to
F h
Irigger event centers will bring health comDro of
Syndrome
people. The health
centers will provide
maternal and child health cSive
single case ot
severe
A
Acute watery dehydration/death in a patient health care, including
stools
5years of age with
diarrhoea. Communicable Diseases services, ana o
services related
begin with
having at Non-Communicable Diseases.
More than 10 houses diabetes and
loose stools common NCDS Such as nypertension,cervix. Jt is
east one case of or common cancers of oral, breast and
irrespective of age, per village primary healthe
an urban ward. envisaged to incrementally add ENT, opthalmolo are
services for mental health, ogy,
health, geriatric and palliative health
care and traums
Fever < 7 days
duration care, as well as health promotion and
wellness activitioe
5 cases in 1000 population. like Yoga. A tew States/uIs have already started
rolin
(a) Only fever in phasod
(b) With rash Two similar cases in a village out these additional packages of services a

(Measles (1000 population). manner. The centers will also provide free essential druos
Dengue) and diagnostic services.
(c) Altered Iwo cases of fever withaltered 2. The second component 1s the Ayushman Bharat
consciousness consciousness in the village/1O00 Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) which
population. provides health coverage upto Rs. 5.00 lakh per family
Two cases of fever with bleeding in a
per year to about 10.74 crore poor and vulnerable
(d) Fever with
bleeding village or 1000 population. families identified on the basis of Socio Economic Caste
Two cases of fever with convulsions Census data.
Fever with
convulsions in a village or 1000 population. The first Health and Wellness Centre was inaugurated on
Fever more More than 2 cases in a village or 1000 14th April 2018 in Bijapur district of Chhattisgarh. So far,
than 7 days population. 22,559 centres are operational in the country as on 22nd
Jaundice More than 2 cases in a village or in October 2019, which includes 8,075 SHC-HWCs, 11,716
1000 population. PHC-HWCs and 2,769 UPHC-HWCs (11).
Unusual event More than 2 deaths or Primary healthcare team at the Sub Health Centre level
hospitalization. AB-HWCs is headed by Community Health Officer (CHO)

The reporting units for disease surveillance are

who is a BSc/GNM Nurse or an Ayurveda Practitioner
trained in primary care and public health skills, and certified
Public Health Sector Private Health Sector in a six months certificate programme in community health.
Other members of the team being multi-purpose workers
Rural CHCs, District Sentinel private (Male and Female) and Accredited Social Health ActivVIsts
hospitals practitioners, and (ASHAs)
Sentinel hospitals. The training programme is being carried out with support
Urban Orban hospitals, Sentinel private from IGNOU and state specific Public/Health Universities.
ESI/ Railway/ nursing homes, 282 IGNOU Programme Study Centres (PSCs) have bee
Medical college hospitals. sentinel hospitals,
notified so far, and another 111 PSCs have been notiie
Medical colleges, under the state specific certificate programme
Private and in the state o
Maharashtra, Tamil Nadu, Gujarat and West
NGO laboratories tne total of programme
Bengal, tak
1. Sub-centre-health worker/ANM study centres to 393 across
reports all patients country.
fulfilling the clinical
syndrome from PHC, private Since the screening,
clinic, hospital etc. prevention managemen
2. PHC/CHC medical officers chronic illnesses including NCDs, and
report as probable cases of been introduced at AB-HWCs,
TB and Leprosy
interest, where this cannot training and skill upgradau
be contirmed by O the primary health team
tests at the
peripheral reporting units,laboratory NCDs and use of IT in all the functional AB-HW
confirmed when the and as application is being
available as in case of laboratory intormation is lo promote wellness done.
blood smear +ve
sputum AFB +ve tuberculosis. and healthy lifestyle, orientatio
malaria and the public on wellness
3. Sentinel private activities for lifestyle
municipal hospitals,
practitioners, district increased physical modiican=
activity (cyclathons and mara
hospitals, eating RIGHT and SAFE,
hospitals, NGOs medical colleges, dru
medical officers
- sentinel meditation, laughter cessation of tobacco a
cases of interest. report as probable clubs, open gyms, e
Beside these, Yoga
centres on regular sessions are being conducte d at the
basis. Through annual healt calend
 AYUSHM: BARAT PREHGRAMM 53
ities at these cenes on the health condilion
planned ct.resulting in increased awareness and ernational Commission for Certification of Dracunculiasis
are preventive
day
theday1o be adopted by the public. Eradication, Geneva :

special emphasis on
icine guidelines have also been provided to .Health education activities with rural areas;
The tele School children and wonen in
initiate speclalis consuliations from
the
Sta the Hub Hospilals ana ne piot o1 the application is . Rumour registration and rumour investigation
Maintenance of guinea-worm disease on list n
PHCs to ot
nducted n Andhra Pradesh, Tamil Nadu and C.
being nofifiable disease and continuationi of survellance
aharasntra.
Mah ed service packages planned to be provided previously infected areas, and
of hand pumps
AB-HWCs are as 1ollows Careful supervision of the functioning water, and
functional and other sources of safe drinkingnecessary.
pregnancy and child birth. provision of additional units, wherever
Care in
anatal and intant health care services.
2 hood and adolescent health care services. YAWS ERADICATION PROGRAMME (9)
Family planning. contraceptive services and other ne disease has been reported in India from the triba
ctive health care services. areas
living in hilly forest and difficult to
reach
anagement of communicable diseases
National unities
in 49 districts of 10 states, namely Andhra Pradesh.
programmes. Gujarat, Jharkhand. Madhya Pradesn,
Health nattisgarh, and Uttar Pradesn.
Ceneral out-patient care 1or acute simple illnesses and ianarashfra, Orissa, Tamil Nadu
is the nodal
6.
minor ailments. Institute of Communicable Diseases
aOna
agency or planning, guidance, coordination, moiitorng
Screening. prevention, control and managemen on
comm and evaluation of the programme. The progranne
communicable alseases and e onic
and chronic communicable ot Yaws
tuberculosis mpiemented by the State Health Directorates system
diseases like
endemic states utilizing existing health care delivery
S. Basic oral
health care. ot department ot
WIh the coordination and collaboration
o Screening and basic management of mental health tribal weltare and other related institutions.
ailments. The number of reported cases has come down from more
10. Care for
common ophthalmic and ENT problem. than 3,500 to Nil during the period from 1995 to
2004.
11.Elderly and palliative health care services. since then no new case has been reported.
12.Emergency medical services including burns and trauma.
NATIONAL PROGRAMME FOR CONTROL AND
Expected outcome (11) TREATMENT OF OCCUPATIONAL DISEASESS
Increasing the trust of people on the service provision by Government launched a scheme called "National
of India
public healthcare facilities through health system Programme for Control and Treatment of Occupational
strengthening and improvement. Diseases" in 1998-99. The National Institute oft
Availability of assured healthcare services to ensure Occupational Health, Ahmedabad (ICMR) has been
continuum ot care. identified as the nodal agency tor this programme.
Reduction in out of pocket expenditure of the common The following research projects have been proposed by
people.
the government (70):
Increased awareness among the people about preventive 1. Prevention, control and treatment of silicosis and
and promotive healthcare. silico-tuberculosis in agate industry:
Benefits of healthy lifestyle including Yoga, and eat right 2. Occupational health problems of tobacco harvesters
& eat safe etc.
and their prevention;
Enabling environment to increase the health seeking 3. Hazardous process and chemicals, database
behaviour of the poor people. documentation, information
generation, and
dissemination;
NATIONAL GUINEAwORM 4. Capacity building to promote research, education,
ERADICATION PROGRAMME and training at National Institute of Occupational
Disease;
India launched its National Guineaworm Eradication 5. Health Risk Assessment and development of
rogramme in 1984 with technical assistance from WHO.
intervention programme in cottage industries with
rom the very beginning the programme was integrated into high risk of silicosis; and
ne national health system
at village level. With well defined 6. Prevention and control of occupational health hazards
egies, an efficient information and evaluation sysrem, among salt workers in the remote desert areas of
ersectoral coordination at all levels and close collaboration Gujarat and Western Rajasthan.
WHO and UNICEF, India was able to significantly reduce
aisease in affected areas. The country has reported zero NUTRITIONAL PROGRAMME
s since August 1996. In February2000, the International
mission for the Certification of Dracuncullasi Please refer to chapter 12, for details.
cation recommended that India be certified tree or
oracunculiasis transmission
(00/ NATIONAL FAMILY WELFARE PROGRAMME
1llowingactivities are continuing as per See chapter 10 for details.
atons of International Certification Team of
 Essential Medicines
8 and Counterfeit Medicines
against humanity
Counterfeit medicines are a crime

(1) 7. Price of the total treatment to be considered and not the

cept of essential medicines unit price of a medicine;
al medicines are those that satisfy the priority 8. Fixed dose combination are generally
not included
re needs of the population. ESsential medicines are unless the combination has unequivocally proven
of functioning administered
to be available within the context advantage over individual ingredients reducing side
amounts, in the
Jstems at all times in adequate and
separately in terms of increasing etficacy,
ate dosage forms, with assured quality effects and/or improving compliance;
price the individual and the is based according to the
information, and at a
of the concept 9. The list of essential medicines
ity can afford. The implementation Primary (P), Secondary (S) and
to be flexible and level of health care i.e.
medicines is intended treatment facility, training,
ntial
situations; exactly which tertiary (T) because the of health care personnel
le to many diflerent experience and availability
es are regarded as essential remains a national
careful selection of differ at these levels.
ibility. Experience has shown that
d range of essential
medicines results in a higher Dosage forms/formulations of a
medicine
of care, better
management of medicines (including Formulation of a medicine may be
available in different
medicines), and a more cost solid dosage form includes tablet,
2d quality of prescribed resources. dosage forms. Oral Tablets include immediate-release
e useof available health capsule,, sachet etc. uncoated, sugar coated, crushable,
of tablets like film coated, etc. Enteric coated on the other
nal list of essential medicines chewable and dispersible Crushable, chewable
and
-2015 (2) modifies drug release. administer to paediatric
hand, be easier to
Essential Medicines in India was dispersible tablets may capsue,
first National List of subsequently revised cases. Capsules include hard gelatin
capsules
ed in the year 1996, this list was and elderly
capsule etc. (unless
specitied,
year 2003, 2011 and 2015. Soit gelatin considered as hard, gelatin
according to are
mentioned in the list
medicines have been categorizeda medicine with capsules). syrup, suspension,
possible that forms include
eutic use, hence, it is appears in more than one dosage oru
than one indication Oral liquid
Injectable dosage forms include con as aenv
elixirs etc. injection, as well
ory. Medicines as or powder for etc 0pca
concept of Essential quia in)Jection
depot, liposomal/ lipid complex
drops etc
dia has adopted the However, India's list of essential system Ike ointment, cream,
lotion,
Dunced by the WHO. to torms include
by WHO due dosage pharmacovigilance
is different from the list issued essential safety and
cines circumstances. The list of
Monitoring of medicine
ences in national medicines that satisty the priority part of the o
such its own monitoring is an important the varnou u
cines contains country's population, addressingnational atety medicine use. The aims of new, prevo
h needs of the medicines used in various surveillance of identify
pharmacovigilance are to medicines, to quant latory
burden. The
seprogrammes, re-emerging infections of effects of
emerging and medicines. The criteria unrecognized adverse uant the
th of essential communicate these to
ncluded in this list national list is as risks, and to
professionals, ana, we dicines,
a medicine in authorities, health etfects O nld
for inclusion
of
approved/licensed in India; puoic. voluntary reporting
International
of adverseProgramme
WHO a
of
ws( be on which the based, has been effective The in ident
should which is a ma cing
The medicine in disease Monitoring is effects.
evaacase
should be usetul previously undescribed
The medicineproblem in India; number of adverse effects is generaly such
public health profile based the risk of epidemiological methods,
proven etficacy and saiety bservational case-population studies. essential
have etical
It shouldscientific evidence; control, cohort and India approved listo
on valid effective; Government of Medicines are listed in aip
cost guidelines The
It should be the current treatment meaicines is as
tollows.
aligned with (2).
It should be order within sections
disease; storage conditions in India;
for the
stable under the
It should be
 NATIONAL LIST OF ESSENTIALL
MEDICINEES 541
National list of essential medicines 2015
Level of Dosage form and strength Medicines Level ol Dosage form and strength
Medicines
Healthcare Healthcare
Section 1: Anestheticagents 2.2: Oploid analgesics
1.1 General Anesthetics and oxygen 2.2.1 Fentanyl S,T Injection 50 meg/ml
Halothane S,T Inhalation PS,T Tablet 10 mg
2.2.2 Morphine
1.1.1 Injection 10 mg/ml
1.1.2 Isofturane S,T Inhalation Injection 15 mg/ml
1.1.3 Ketamine PS,T Injection 10 mg/ml Capsule 50 mg
Injection 50 mg/ml 2.2.3 Tramadol S,T
Capsule 100 mg
1.14
Nitrous oxide PS,T Inhalation Injection 50 mg/ml
1.1.5 Oxygen PS,T Inhalation (Medicinal gas)
2.3 Medicines used to treat gout
1,1.6 Propofol PS,T Injection 10 mg/ml PS,T Tablet 100 mg
2.3.1 Allopurinol
1.1.7 Sevoflurane T Inhalation Tablet 300 mg
1.1.8 Thiopentone PS,T Powder for Injection 0.5 g 2.3.2 Colchicine PS,T Tablet 0.5 mg
Powder for Injectionlg
2.4: Disease modifying agents
1.2: Local anesthetics used in rheumatoid disorders
1.2.1 Bupivacaine S,T Injection 0.25% 2.4.1 Azathioprine S, T Tablet 50 mg
Injection 0.5% Tablet 200 mg
Injection 0.5% with 2.4.2 Hydroxy- S,T
chloroquine Tablet 400 mg
7.5% glucose
2.4.3 Leflunomide S,T Tablet 10 mg
1.2.2 Lignocaine P.S,T Topical forms 2-5%
Injection 1% Tablet 20 mg
Injection 2% 2.4.4 Methotrexate S,T Tablet 5 mg
Injection 5% with Tablet 7.5 mg
7.5% Glucose Tablet 10 mg
Injection 1% (A) + Injection 25 mg/ ml
1.2.3 Lignocaine (A) + PS,T
Adrenaline (B) 1:200000(5 mcg/ml) (B) 2.4.5 Sulfasalazine S, T Tablet 500 mg
Injection 2% (A) +
Section 3: Antiallergics and medicines used in anaphylaxis
1:200000 (5 mcg/ml) (B)
3.1 Adrenaline PS,T Injection 1 mg/ml
1.2.4 Prilocaine (A) T Cream 2.5% (A) +
Lignocaine (B) 2.5% (B) 3.2 Cetirizine PS,T Tablet 10 mg
Oral liquid 5 mg/5 ml
1.3 Preoperative medication and sedation for
short term procedures 3.3 Chlorpheniramine PS,T Tablet 4 mng
Oral liquid 2 mg/5 ml
1.3.1 Atropine RS,T Injection 0.6 mg/ml
3.4 Dexamethasone PS,T Tablet 0.5 mg
1.3.2 Glycopyrrolate S,T Injection 0.2 mg/ml
Injection 4 mg/ml
13.3 Midazolam PS,T Tablet 7.5 mg 3.5 Hydrocortisone PS,T Powder for Injection 100mg
Tablet 15 mg
3.6 Pheniramine PS,T Injection 22.75 mg/ml
Oral liquid 2 mg/ml i3
Injection 1 mg/mi 3.7 Prednisolones RS,T Tablet 5 mg
Injection 5 mg/ml Tablet 10 mg
1.3.4 Morphine PS,T Injection 10 mg/ml Tablet 20 mg
Injection15 mg/ml Oral liquid 5 mg/5 ml
Oral liquid 15 mg/5 ml
Section 2: Analgesics, antipyretics, non steroidal anti-
ntlammatory medicines, medicines used to treat gout and Section 4: Antidotes and other
disease modifying agents used in rheumatoid disorders substances used in poisoning

2.1 Non-opioid analgesics, antipyretics and 4.1 Nonspecific

nonsteroidal anti-inflammatory medicines 4.1.1 Activated charcoal PS,T Powder (as licensed)
2.1.1 Acetylsalicylic
PS,T Tablet 300 mg to 500 mg 4.2:Specific
acid Effervescent/ Dispersible/ 4.2.1 Atropine PS,T Injection 1 mg/ml
Enteric coated
Tablet 300 mg to 500 mg 4.2.2 Calcium PS,T Injection 100 mg/ml
2.1.2 gluconate
Diclofenac P.S,T Tablet 50 mg
4.2.3 Desferrioxamine S,T
Injection 25 mg/ml Powder for
2.1.3 tbuprofen PS,T Tablet 200 mg njection 500 mg
Tablet 400 mg 4.2.4 Dimercaprol S,T Injection 50 mg/ml
Oral liquid 100 mg/5 ml 4.2.5 Methylthioni- S,T Injection 10 mg/ml
2.14 Mefenamic RS,T Capsule 250 mg nium chloride
Methylene blue)
acid Capsule 500mg
Oral liquid 100 mg/5 ml 4.2.6 N-acetylcysteine Ps,T Sachet 200 mg
2.15 Paracetamol PS,T Tablet 500 mg Injection 200 mg/ml
Tablet 650 mg 4.2.7 Naloxone PS,T Injection 0.4 mg/ml
All licenced oral liquid 4.2.8 Neostigmine PS,T Injection 0.5 mg/ml
dosage forms and strengths 4.2.9 Penicillamine S,T
Injection 150 mg/ml Capsule 250 mg
Suppository 80 mg 4.2.10 Pralidoxime PS,T Injection 25 mg/mi
Suppository 170 mgg chloride (2-PAM)
 542 ESSENTIAL MEDICINES AND COUNTERFEIT MEDICINES

Medicines Level of Dosage form and strength Medicines Level of Dosage form and strength
Healthcare Healthcare
4.2.11 Snake venom PS,T 6.2: Antibacterials
antiserum 6.2.1: Beta lactam medicines
a) Soluble/ liquid a) Injection
polyvalent 6.2.1.1 Amoxicillin PS,T Capsule 250 mg
b) Lyophilized b) Powder for Injection Capsule 500 mg
polyvalent Oral liquid 250 mg/5ml
4.2.12 Sodium nitrite S,T Injection 30 mg/ml 6.2.1.2 Amoxicillin (A) + PS,T Tablet 500 mg (A)+
Clavulanic acid (B) 125 mg (B)
4.2.13 Sodium S,T Injection 100 mg/mi Oral liquid 200 mg (A)+
thiosulphate
28.5 mg (B)/5 ml
Section 5: Anticonvulsants/ Antiepileptics Dry Syrup 125 mg (A)+
5.1 Carbamzepine PS,T Tablet 100 mg 31.25 (B)/5 ml
Tablet 200 mg S,T Powder for Injection
CR Tablet 200 mg 500 mg (A) +100 mg (B)
Tablet 400 mg Powder for Injection
CR Tablet 400 mg 1g (A) +200 mg (B)
Oral liquid 100 mg/5 ml
Oral liquid 200 mg/5 ml
6.2.1.3 Ampicillin PS,Ts Powder for Injection 500mg
Powder for Injection 1g
5.2 Clobazam S,T Tablet 5 mg 6.2.1.4 Benzathine PS,T Powder for Injection
Tablet 10 mg benzylpenicillin
5.3 Diazepam PS,T Oral liquid 2 mg/5 ml
lacunits
6Powder for Injection
Injection 5 mg/ml 12 lac unitsar
Suppository 5 mg 6.2.1.5 Benzyl penicillin PS,T Powder for Injection
5.4 Levetiracetam S,T Tablet 250 mg 10 lac units
Tablet 500 mg RS,T Tablet 500 mg
6.2.1.6 Cefadroxil
Tablet 750 mg
ER Tablet 750 mg
Tablet 1 g
Oral liquid 125 mg/5 ml
Oral liquid 100 mg/ml
Injection 100 mg/ml 6.2.1.7 Cefazolin PS,T Powder for Injection 500mg
Powder for Injection 11g
5.5 Lorazepam PS,T Tablet 1 mg
Tablet 2 mg 6.2.1.8 Cefixime S,T Tablet 200 mg
Injection 2 mg/ml Tablet 400 mg
Oral liquid 50 mg/5 ml
5.6 Magnesium s,T Injection 500 mg/ml liquid 100 mg/5 m
sulphate R Oral
6.2.1.9 Cefotaxime S,T Powder for Injection 250mg
5.7 Phenobarbitone PS,T Tablet 30 mg Tablet 60 mg Powder for Injection 500mg
Oral liquid 20 mg/5 ml Powder for Injection 1 9
S,T Injection 200 mg/ml 6.2.1.10 CeftazidimestS,T Powderfor Injection250mg
Phenytoin PS,T Tablet 50 mg Powder for Injectiong
Tablet 100 mg 6.2.1.11 Ceftriaxone S,T Powder for Injection 250mg
Tablet 300 mg Powder for Injection 500mg
ER Tablet 300 mg Powder for Injection 1g
Oral liquid 30 mg/5 m Powder for Injection 29
Oralliquid 125 mg/5 ml 6.2.1.12 Cloxacilin Ps,T Capsule 250 mg
Injection 25 mg/ml
niection 50 mgml 27i t Capsule.sung
Oral Liquld 125 mg
5.9 Sodium PST Tablet 200mg te a Powder forInjection z
valproate Tablet 300 mg 6.2.1.13 Piperacillin (A) + T i Powder for Injection
CRTablet 300 mg A):t125mgp
Tablet 500 mg azobactam (B)snfisei1g
Powder for Injection
CR Tablet 500 mg mg
2 g(A) + 250 (B
Oral liquid 200mg/5ml Powder for Injectión
Injection 100mg/ml 4g(A) +500mg (B)
Section 6.. Anti infective medicines 6.2.2:Other antibacterlals
6.1 Anthelminthics 6.2.2.1 Azithromycin PS,T Tablet 250 mg
Tablet 500 mg
6:1.1 Intestinal anthelminthicsmg Oral liquid 200 mg/5m
500mg
PS,T Tablet 400
6111 Albendazole Powder for Injection
Oral liquid 200 mg/5 ml
6.2.2.2 Ciprofloxacin PS,T Tablet 250 mg
6.11.2 Mebendazole PS,T Tablet 100 mg Tablet 500 mg
mg/5m
Oral liquid 100 mg/5 ml Oral liquid 250mg/10Um
6.1.2: Antifilarial Injection 200
6.2.2.3 Clarithromycin S,T Tablet 250 mg
PS,T Tablet 50 mg mg
6.1.2.1 Diethylcarba- Tablet 100 mg lablet 500 125mg5
mazine
Oral liquid 120 mg/5 ml Oral liquid
6.2.2.4Co-trimoxazole Tablet 400 mg (A
medicine
6.1.3: Anti-schistosomal & anti-trematodal [Sulphamethoxa- 80mg (B) +
6.1.3.1 Praziquantel S,T Tablet 600 mg zole(A) 4 Tablet 800 mg (A)
 NATIONAL LIST OF ESSENTIAL MEDICINES 543
Level of Dosage form and strength Medicines Level of Dosage form and strength
Medicines
Healthcare Healthcare
Trimethoprim (B)]| 60 mg (B) 6.3: Antifungal medicines
Oral liquid 200 mg (A) +
6.3.1 Amphotericin B S,T Powder for Injection 50 mg
40 mg (B)/5 ml a) Amphotericin B
Doxycycline PS,T Capsule 100 mg (conventional)
6.2.2.5 Dry Syrup 50mg/5 ml b) Lipid/ Liposomal
Amphotericin B
Gentamicin P.S,T Injection 10 mg/ml
6.2.2.6 6.3.2 Clotrimazole PS,T Pessary 100 mg
Injection 40 mg/ml
6.3.3 Fluconazole PS,T Tablet 100 mg
Metronidazole PS,T Tablet 200 mg Tablet 150 mg
6.2.2.7
Tablet 400 mg Tablet 200 mg
Oral liquid 200 mg/5 ml Tablet 400 mg
Injection 500 mg/100 ml Oral liquid 50 mg/5 ml
6.2.2.8 Nitrofurantoin PS,T Tablet 100 mg s,T Injection 200 mg /100 ml
Oral liquid 25 mg/5 ml Tablet 125 mg
6.3.4 Griseofulvin PS,T
6.2.2.9 Vancomycin Powder for Injection 250mg Tablet 250 mg
Powder for Injection 500mg Tablet 375 mg
Powder for Injection 1g 6.3.5 Nystatin PS,T Tablet 500,000 IU
Pessary 100,000 IU
6.2.3: Antileprosy medicines Oral Liquid 100, 000 IU/ml
6.2.3.1 Clofazimine P.S,T Capsule 50 mg
Capsule 100 mg 6.4 Antiviral medicines
6.2.3.2 Dapsone PS,T Tablet 25 mg 6.4.1: Antiherpes medicines
Tablet 50 mg 6.4.1.1 Acyclovir PS,T Tablet 200 mg
Tablet 100 mg Tablet 400 mg
Powder for Injection 250mg
623.3 Rifampicin PS,T Capsule 150 mg
Powder for Injection 500mg
Capsule 300 mg Oral liquid 400 mg/5 ml
6.2.4 Antituberculosis medicines 6.4.2: Anti Cytomegalovirus (CMV) medicines
1
6.2.4.1 Capreomycin PS. T Powder for Injection g9

S,T Capsule 250 mg

nls 6.4.2.1 Ganciclovir
6.2.4.2 Cycloserine PS.T Capsule 125 mg Powder for Injection 500mg
Capsule 250 mg 6.4.3: Antiretroviral medicines
624.3 Ethambutol P.S,T Tablet 200 mg 6.4.3.1 Nucleoside reverse transcriptase inhibitors
Tablet 400 mg
6.4.3.1.1 Abacavir S,T Tablet 60 mg
Tablet 600 mg
ti Tablet 300 mg
Tablet 800 mg
6.2.4.4 Ethionamide 6.4.3.1.2 Abacavir (A) + S,T Tablet 60mg (A)+30mg (B)
P,S,T Tablet 125 mg Lamivudine (B) Tablet 600 mg (A) +
Tablet 250 mg 300 mg (B)
62.4.5 Isoniazid PS,T Tablet 50 mg 6.4.3.1.3 Lamivudine (A) + S,T Dispersible Tablet 30mg (A)
Tablet 100 mg Nevirapine (B) + +50 mg (B) + 6 mg (C)
Tablet 300 mg Stavudine (C) Tablet 150 mg (A) +
Oral liquid 100 mg/5 ml 200 mg (B) + 30 mg (C)
6.2.4.6 Kanamycin
P.S,T Powder for Injection 500mg 6.4.3.1.4 Lamivudine (A) + S,T Tablet 30mg (A)+60mg (B)
Powder for Injection 750mg Zidovudine (B) Tablet 150 mg (A) +
Powder for Injection1g 300 mg (B)
62.4.7 Levofloxacin (A) + S,T Dispersible Tablet 6 mg (A)
PS,T Tablet 250 mg 6.4.3.1.5 Stavudine
Tablet 500 mg Lamivudine (B)
+30 mg (B)
Tablet 750 mg Tablet 30 mg (A) +
62.4.8 Linezolid 150 mg (B)
PS,T Tablet 600 mg S,T
62.4.9 Moxifloxacin 6.4.3.1.6 Tenofovir (A) + Tablet 300 mg (A) +
PS Tablet 200 mg Lamivudine (B) 300 mg (B)
Tablet 400 mg
624.10 6.4.3.1.7 Tenofovir (A) + S,T Tablet 300 mg (A) +
Para- Tablet 500 mg Granules Lamivudine (B) + 300 mg (B) +600 mg (C)
aminosalicylic PS,T
(As licensed) Efavirenz (C)
$2.4.11 Pyrazinamide acid
PS,T Tablet 500 mg 6.4.3.1.8 Zidovudine S,T Tablet 300 mg
Tablet 750 mg Oral liquid 50 mg/5 ml
Tablet 1000 mg 6.4.3.1.9 Zidovudine (A) + S,T Tablet 60 mg (A) +
Tablet 1500 mg Lamivudine (B) + 30 mg (B) + 50 mg (C)
524.12 Oral liquid 250 mg/5 ml Nevirapine (C) Tablet 300 mg (A) +
Rifabutin
Capsule 150 mg 150 mg (B)+ 200 mg (C)
24.13 Rifampicin S,T
6.4.3.2:Non-nucleoside reversetranscriptase inhibitors
P.S,T Capsule 150 mg
Capsule 300 mg 6.4.3.2.1 Efavirenz S,T Tablet 50 mg
Capsule 450 mg Tablet 200 mg
Capsule 600 mg Tablet 600 mg
m
24.14 Oral liquid 100 mg/5 6.4.3.2.2 Nevirapine S,T Dispersible Tablet 50 mg
Streptomycin Tablet 200 mg
PS,I Powder for Injection 750mg
Oral liquid 50 mg/5 ml
Powder for Injection 1g
 544 ESSENTIAL MEDICINES AND COUNTERFEIT MEDICINES

Medicines Level of Dosage form and strength gMedicines Level of Dosage form and strength
Healthcare Healthcare
6.4.3.3: Integrase inhibitors 6.5.3.1.4 Chloroquine PS,T Tablet 150 mg
6.4.3.3.1 Raltegravir S,T Tablet 400 mg Oral liquid 50 mg/5 ml
6.4.3.4 Protease inhibitors 6.5.3.1.5 Clindamycin PS,T Capsule 150 mg
Capsule 300 mg
6.4.3.4.1 Atazanavir (A) + S,T Tablet 300 mg (A) +
Ritonavir (B) 100 mg (B) 6.5.3.1.6 Primaquine PS,T Tablet 2.5 mg
Tablet 7.5 mg
6.4.3.4.2 Darunavir S,T Tablet 600 mg Tablet 15 mg
6.4.3.4.3 Lopinavir (A) + S,T Tablet 100Omg(A)+25mg(B) 6.5.3.1.7 Quinine PS,T Tablet 300 mg
Ritonavir (B) Tablet 200mg(A)+50mg(B) Injection 300 mg/ml
Oral liquid 400 mg (A) +
100 mg (B)/ 5ml 6.5.3.2: For prophylaxis
6.4.3.4.4 Ritonavir S,T Tablet 100 mg 6.5.3.2.1 Mefloquine T Tablet 250 mg
*Only for use as
6.4.4: Medicines for hepatitis B and hepatitis C
chemoprophylaxis for long
6.4.4.1 Entecavir S,T Tablet 0.5 mg term travellers !hke military
Tablet 1 mg and travel troops, travelling
6.4.4.2 Pegylated S,T Injection 180 mcg from low endemic to high
interferon alfa 2a endemicarea.
Pegylated S,T Injection 80 mcg 6.5.4: Antipneumocystosisand
interferon alfa 2b Injection 100 mcg antitoxoplasmosis medicines
Injection 120 mcg 6.5.4.1 Co-trimaxazole PS,T Tablet 400 mg (A) +
6.4.4.3 Ribavirin S,T Capsule 200 mg (Sulphametho- 80 mg (B)
6.4.4.4 Sofosbuvir xazole (A) + Tablet 800 mg (A) +
S,T Tablet 400 mg Trimethoprim (B)] 160 mg (B)
6.4.4.5 Tenofovir S,T Tablet 300 mg Oral liquid 200 mg A)
6.5: Antiprotozoal Medicines 40 mg (B)/5 ml
6.5.1: Antiamoebic and antigiardiasis medicines 6.5.4.2 Pentamidine S,T Powder for Injection 200mg
6.5.1.1 Diloxanide PS,T Tablet 500 mg Section 7 :Antimigraine medicines
furoate 7.1: For treatment of acute attack
6.5.1.2 Metronidazole PS,T Tablet 200 mg 7.1.1 Acetylsalicylic PS,T Tablet 300 mg to 500 mg
u 1Tablet 40O mg acid Effervescent/ Dispersible
r 1
E Injection 500 mg/100 ml
Oral liquid 200 mg/5 ml
i Enteric coated
Tablet 300 mg to 500 mg
6.5.2: Antileishmaniasis medicines 7.1.2 Paracetamold PS,T Tablet 500 mg
6.5.2.1 Amphotericin B S,T PowderforInjection 50 mg Tablet 650 mg
a Amphotericin B 7.1.3 Sumatriptani RS,T Tablet 25 mg
(conventional)
b) Lipidiposomal
Amphotericin B isiai , .13
R .2
Tablet 50 mg
Injection 6m 0.5 m
For prophylaxis.
6:5.2.2 Miltefösine PS;T Capsule 10 mg 7.2.1 Flunarizine i RS,T Tablet 5 mg
Capsule 50 mg
6:5.2.3 Paromomycin Tablet 10 mg
PS,T Injection 375 mg/il 7.2.2 Propranolol. iu,PS,T Tablet 10 mg
6.5.3Antimalarial medicines Tablet 40 mg
6.5.3.For curative treatment Tablet 80mg
6.5.3.1.1 Artemether (A) + PS,T t
Tablet 20mg(A)+120mg(B) Sectlon 8: Antineoplastic/ immunosuppressives ang
Lumefantrine (B Tablet 40 mg (A) + medlcines used in palliative care
240 mg (B): 8.1Antineoplastic medicines
Tablet 80 mg (A) +
480 mg (B)
8.1.1 5-Fluorouracil T T Injection 250 mg/5 m
Oral liquid 80 mg (A) 8.1.2 6-Mercaptopurine T Tablet 50 mg
8.1.3 mg
480 mg (B)/5 ml Actinomycin D Powder for lnjection 0.5
6.5.3.1.2 Artesunate PS,T Powder for Injection 60 mg 8.1.4 All-trans Capsule 10 mg
Powder for Injection 120mg retinoicacid
6.5.3.1.3 Artesunate (A) + PS,T Combi pack (A+B) 8.1.5 Arsenic trioxide T Injection1mg/ml
Sulphadoxine I Tablet 25mg (A)+1: Tablet
8.1.6 Bleomycin
Pyrimethamine (B) (250 mg + 12.5 mg) (B) T Powder for
1 Tablet 50mg (A)+1 Tablet Injection 15 units
8.1.7 Bortezomib Powder for Injection 2mg
(500mg+25 mg) (B)
1 Tablet 100 mg (A)+ 8.1.8 Calcium folinate T Tablet 15 mg
1 Tablet (750 mg +
Injection 3 mg/m
37.5 mg) (B) Capecitabine
1 Tablet 150 mg (A) +
8.1.9 Tablet 500 ms
2 Tablet (500mg+25mg)(B) 8.1.10 Carboplatin Injection 10 mg/ml
1 Tablet 200 mg (A) t 8.1.11 Chlorambucil Tablet 2 mg
2 Tablet (750 mg + Tablet 5 mng
37.5 mg) (B) 8.1.12 Cisplatin Injectlon 1mg/ml
T
 NATIONAI. LIST OF ESSENTIAL. MEDICINES 545
strength
Medicines Level of Dosage form and strenglh Medicines Ievel of Dosage form and
Healthcare Healthchre
**
Cyclophospha- Tablet 50 mg 8,3.2 Cyclosporine T Capsule 10 mg
.13 Capsule 25 mg
mide Tablet 200 mg
Powder for Injection 500mg Capsule 50 mg
Capsule 100 mg
.14 Cytosine Injection 100 mg/ ml Oral liquld 100 mg/ml
arabinoside Powder for Injection 500mg Injection 50 mg/ml
Powder for
Injection 1000 mg 8.3.3 Mycophenolate T Tablet 250 mg
mofetil Tablet 500 mg
.15 Dacarbazine T Powder for Injection 500mg
Powder for Injection 200mg 8.3.4 Tacrolimus Capsule 0.5 mg
Capsule 1 mg
16 Daunorubicin Injection 5 mg/ml Capsule 2 mg
Docetaxel Powder for Injection 20 mg
17
Powder for Injection 80 mg 8.4: Medlclnes used in palllative care
8.4.1 Allopurinol T Tablet 100 mg
.18 Doxorubicin Injection 2 mg/ml
8.4.2 Amitriptyline Tablet 10 mg Tablet 25 mg
19 Etoposide Capsule 50 mg
Capsule 100 mg 8.4.3 Dexamethasone T Tablet 0.5 mg
Injection 20 mg/ml Injection 4 mg/ml
20 Gefitinib T Tablet 250 mg 8.4.4 Dtazepam Tablet 2 mg
Tablet 5 mg
21 Gemcitabine Powder for Injection 200mg Injection 5 mg/ml
Powder for Injection 1 g
8,4.5 Filgrastim Injection 300 meg
22 Ifosfamide T Powder for Injection 1g
Powder for Injection 2g 8.4.6 Fluoxetine Capsule 20 mg
23 Imatinib T Tablet 100 mg 8.4.7 Haloperidol T Tablet 1.5 mg
Tablet 400 mg Tablet 5 mg
Injection 5 mg/ml
24 LAsparaginase T Powderfor
Injection 5000 KU. 8.4.8 Lactulose T Oral liquid 10 g/15 ml
Powder for 8.4.9 Loperamide T Tablet 2 mg
Injection 10000 KU
25 Melphalan Tablet 2 mg
8.4.10 Metaclopramide T Tablet 10 mg
Oral liquid 5 mg/5 ml
Tablet 5 mg Injection 5 mg/ml
26 Mesna Injection 100 mg/ml 8.4.11 Midazolam Injection 1 mg/ml
7 Methotrexate Tablet 2.5 mg 8.4.12 Morphine Tablet 10 mg
ora 1 Tablet 5 mng Tablet 20 mg
Tablet 10 mg Tablet 30 mg SR
Injection 50 mg/ml Tablet 4 mg
8.4.13 Ondansetron S,T
8 Oxaliplatin Injection 5 mg/ml Tablet 8 mg
9
Paclitaxel Injection 30 mg/5 ml Oral liquid 2 mg/5 ml
Injection 100 mg/16.7 ml Injection 2 mg/ml
0 Procarbazine Capsule 50 mg 8.4.14 Tramado Capsule 50 mg
t43E5*a 5t Capsule 100 mg
Rituximab Injection 10 mg/ml e podte i.f.t Injection 50 mg/ml
2 Temozolomide T Capsule 20 mg T
Capsule 100 mg 8.4.15 Zoledronic acid Powder for Injection 4 mg
Capsule 250 mg Section 9: Antiparkinsonism medicines
3 Thalidomide T Capsule 50 mng 9.1 Levodopa (A)+ PS,T Tablet 100 mg (A) +
Capsule 100 mg Carbidopa (B) 10 mg (B)
Injection 440 mg/50 ml Tablet 100 mg (A) +
Trastuzumab
25 mg (B)
Vinblastine T Injection 1 mg/ml CR Tablet 100 mg (A) +
Vincristine T Injection 1 mg/ml 25 mg (B))
CR Tablet 200 mg (A) +
ormones and antihormones used in cancer therapy
50 (B) mng
Bicalutamide T Tablet 50 mg s sn.Tablet mg
250 mg (A) +
Letrozole T Tablet 2.5 mg idgi ir25 (B)
Prednisolone Tablet 10 mg 9.2 Trihexyphenidyl PS,T Tablet 2 mg
S, T
Tablet 20 mg Section 10: Medicines affecting blood
Tablet40 mg
Oral liquid 5 mg/5
m 10.1: Antianaemia medicines
Oral liquid 15 mg/5 ml 10.1.1 Erythropoietin S,T Injection 2000 IU/ml
Injection 20 mg/2 ml Injection 10000 IU/ml
Tablet 10 mg 10.1.2 Ferrous salts PS,T Tablet equivalent to 60 mg
amoxifen
Tablet 20 mg of elemental iron
Oral liquid equivalent to
3Immunosuppressive medicines 25 mg of elemental iron/ml
Azathioprine T Tablet 50 mg
 546 ESSENTIAL MEDICINES AND COUNTERFEIT MEDICINES

Medicines Level of Dosage form and strength Medicines Level of Dosage form and strength
Healthcare Healthcare
10.1.3 Ferrous salt (A) + PS,T Tablet 45 mg elemental iron 12.1.2 Clopidogrel PS,T Tablet 75 mg
Folic acid (B) (A) +400 mcg (B) 12.1.3 Diltiazem PS,T Tablet 30 mg
Tablet 100 mg elemental Tablet 60 mg
iron (A) + 500 mcg (B) SR Tablet 90 mg
Oral liqiud 20 mg elemental
iron (A) + 100 mcg (B}/ml T Injection 5 mg/ml
10.1.4 Folic acid PS,T Tablet 5 mng 12.1.4 Glyceryl PS,T Sublingual tablet 0.5 mg
10.1.5 Hydroxoco PS,T Injection 1 mg/ml trinitrate
balamin S,T Injection 5 mg/ml
10.1.6 Hydroxyura PS,T Capsule 500 mg
12.1.5 Isosorbide-5- PS,T Tablet 10 mg
10.1.7 Iron sucrose S,T Injection 20 mg/ml mononitrate" Tablet 20 mg
10.2 Medicines affecting coagulation SR Tablet 30 mg
10.2.1 Enoxaparin T Injection 40 mg/0.4 ml SR Tablet 60 mg
Injection 60 mg/0.6 m 12.1.6 Isosorbide PS,T Tablet 5 mg
10.2.2 Heparin S,T Injection 1000 IU/ml dinitrate Tablet 10 mg
Injection 5000 1U/ml
12.1.7 Metoprolol PS,T Tablet 25 mg
10.2.3 Phytomenadione Ps,T Tablet 10mmg Tablet 50 mg
(Vitamin K,) Injection 10 mg/ml
SR Tablet 25 mg
2.4 Protamine S,T Injection 10 mg/ml SR Tablet 50 mg
10.2.5 Tranexamic acid P.S,T Tablet 500 mg
Injection 100 mg/ml 12.2: Antiarrhythmic medicines
10.2.6 Warfarin S,T Tablet 1mg 12.2.1 Adenosine S,T Injection 3 mg/ml
Tablet 2 mg
Tablet 3 mg 12.2.2 Amiodarone S,T Tablet 100 mg
Tablet 5 mg Tablet 200 mg
Injection 50 mg/ml
Section 11 Blood products and Plasma substitutes
11.1: Blood and Blood components 12.2.3 Esmolol T Injection 10 mg/ml
All forms of the following as approved by licensing authority are 12.2.4 Lignocaine S,T Injection 2% (Preservative
considered as included in NLEM, However, considering the process, free for IV use)
technology and other relevant aspects, they should be considered 12.2.5 Verapamil ST Tablet 40 mg
differently for purposes such as procurement policy, pricing etc. Tablet 80 mg
111.1 Fresh frozen S,T Aslicensed Injection 2.5 mg/ml
plasma
11:1:2 Platelet rich S,T As licensed 12.3: Antihypertensive medicines
plasma 12.3.1 Amlodipinesin, PS,T Tablet 2.5 mg
Red blood cells S,T As licensed Tablet 5 mg
11.1.3 Tablet 10 mg
11.14 Whole blood S,T As licensed
12.3.2 Atenolol PS,T Tablet 50 mg
Dextran-40
11.2 Plasma substitutes
S,T Injection 10%
: Tablet 100 mg
11:2.1
for specific use 12.3.3 Enalapril PS,T Tablet 2.5 mg
11.3 Plasma fractions Tablet 5 mg
In case of coagulation factors and other blood products, irrespective of
variation in source, all forms of these products as approved by 12.3.4 Hydrochloro- BS,T Tablet 12.5 mg
licensing authority are considered as inclided in NLEM. However,
considering "the source, prOcess, technology and other relevant
thiazide a Tablet 25 mg
Injection mg/ml
aspects, they shouid be considered differently for purposes such as 12.3.5 Labetalol PS,T 5
procurement policy, pricing etc. 12.3.6 Methyldopa PS,T Tablet 250 mg
Coagulation S,T Powder for Injection 600 IU Tablet 500 mg
11.3.1
factor IX 12.3.7 Ramipril3 PS,T Tablet 2.5mg
11.3.2 Coagulation S,T Powder for Injection 250 1U Tablet 5 mg
factor VIl Powder for Injection 500 IU 10 mg/ml
As licensed
12.3.8 Sodium sTwtdiInjection
11.3.3 Cryoprecipitate S,T nitroprusside
Section 12: Cardiovascular medicines 12.3.9 Telmisartan PS,T Tablet 20mg
12.1 Medicines used in angina Tablet 40 mg
PS,T Tablet 75 mg Effervescent/ Tablet 80 mg
12.1.1 Acetylsalicylic
àcid Dispersible/ Enteric coated 12.4: Medicines used in shock and heart ta
Tablet 75 mg
Tablet 100 mg 12.4.1Digoxin S.T Tablet 0.25 mg
mg
Effervescent/ Dispersible/ Oral liquid 0.05
Enteric coated Injection 0.25 mg/mi
Tablet 100 mg
12.4.2 Dobutamine Injection 50 mgm
Tablet 150 mg S,1
Effervescent/ Dispersible/ 12.4.3 Dopamine S.Tgnjection
Enteric coated
Tablet 150 mg 12.4.4 Noradrenaline S,T Injection 2 mgm
 NATIONAL LIST OF ESSENTIAL
MEDICINES 547
Medicines Level of Dosage torm and strength Medicines Level of Dosage form and strength
Healthcare Healthcare
12.5: Antithrombotic medicine 15.2 Radiocontrast media
w/wv
(Cardiovascular/ Cerebrovascular) 15.2.1 Barium sulphate S,T Oral liquid 100%
Acetylsalicylic Oral liquid 250% w/v
12.5.1
PS.T Tablet 75 mg
acid Efervescent/ Dispersible/ Injection 529 mg/ml
Enteric coated Tablet 75 mg
15.2.2 Gadobenate
Tablet 100 mg 15.2.3 lohexol S,T Injection 140 to 350 mg
iodine/ml
Effervescent/ Dispersible/
Enteric coated 15.2.4 Meglumine S,T Injection 60% w/v
Tablet 100 mg diatrizoate Injection 76% w/v
Tablet 150 mg
Effervescent/ Dispersible/ Section 16 : Dialysis solutions
Enteric coated 16.1 Haemodialysis S,T As licensed
Tablet 150 mg fluid
12.5.2 Alteplase Powder for Injection 20 mg 16.2 Intraperitoneal S,T As licensed
Powder for Injection 50 mg dialysis solution
12.5.3 Heparin S,T Injection 1000 IU/ml Section 17: Disinfectants and antiseptics
Injection 5000 IU/ml
17.1:Antiseptics
12.5.4 Streptokinase S,T Injection 750,000 1U RS,T Solution 20%
17.1.1 Cetrimide
Injection 15,00,000 IU (Concentrate for dilution)
12.6 Hypolipidemic medicines 17.1.2 Chlorhexidine PS,T Solution 5%
12.6.1 Atorvastatin PS, Tablet 10 mg (Concentrate for dilution)
Tablet 20 mg Solution 70%
Tablet 40 mg 17.1.3 Ethyl alcohol PS,T
(Denatured)
Section 13: Medicines used in dementia 17.1.4 Hydrogen PS,T Solution 6%
13.1 Donepezil S,T Tablet 5 mng peroxide
Tablet 10 mg
: 17.1.5 Methylrosani- PS,T Topial preparation
Section 14 Dermatological medicines (Topical) linium chloride 0.25% to 2%
14.1 Antifungal medicines (Gentian Violet)
141.1 Clotrimazole PS,T Cream 1% 17.1.6 Povidone iodine PS,T Solution 4% to 10%
14.2 Antiinfective medicines 17.2:Disinfectants
14.2.1 Framycetin PS,T Cream 0.5% 17.2.1 Bleaching powder PS,T Containing not less than
14.2.2 Fusidic acid Cream 2% 30% w/w of available
PS,T
chlorine (as per I.P)
14.2.3 Methylrosani PS,T Topial preparation
linium chloride 17.2.2 Glutaraldehyde S,T 5Solution 2%
0.25% to 2%
(Gentian Violet) 17.2.3 Potassium PS,T Crystals for topical solution
14.2.4 Povidone iodine PS,T Solution 4% to 10% permanganate
14.2.5 Silver PS,T Cream 1% Section 18:Diuretics
sulphadiazine 18.1 Furosemide PS,T Tablet 40 mg
Oral liquid 10 mg/ml
14.3.1
4.3: Antiinflamatory medicines
and antipruritic
Injection 10 mg/ ml
Betamethasone PS,T Cream 0.05%
Cream 0.1% 18.2 Hydrochloro PS,T Tablet 25 mg
14.3.2 thiazide Tablet 50 mg
Calamine PS,T Lotion (As per IP).
18.3 Mannitol PS,T Injection 10%
14.4: Medicines affecting skin Injection 20%
differentiation and proliferation
4.4.1 18.4 Spironolactone RS,T Tablet 25 mg
Benzoyl peroxide PS,T Gel 2.5%
14.4.2 Tablet 50 mg
Coal tar PS,T Solution 5%
144.3 Podophyllin resin S Solution 10% to 25%
Section 19:Ear, nose and throat medicines
144.4 19.1 Budesonide PS,T Nasal Spray 50 mcg/dose
Salicylic acid Ointment 6%
PS,T Nasal Spray 100 mcg/dose
145:Permethrin 14.5:Scabicides and pediculicides 19.2 Ciprofloxacin Ps,T Drops 0.3 %
PS,T Lotion 1 19.3 Clotrimazole Ps,T Drops 1%
Cream 5% 19.4 Xylometazoline PS,T Nasal drops 0.05 %
6.1 Glycerin 14.6::MiscellaneousLiquid Nasal drops 0.1 %
PS,T Oral Section 20: Gastrointestinal medicines
6.2 White Petrolatum PS Jelly 100% 20.1 Antiulcer medicines
Section 15 Diagnostic agents 20.1.1 Omeprazole RS,T Capsule 10 mg
15.1.1 15.1:Ophthalmicmedicines Capsule 20 mg
Fluorescein Eye drop 1% Capsule 40 mg
5.12 LignocaineST Powder for oral liquid
20mg
513 ST Eye drop 4%
Tropicamide 20.1.2 Pantoprazole S,T Injection 40 mg
sT Eye drop 1%
 ESSENTIAL MEDICINES AND COUNTERFEIT MEDICINES

Medicines Level of Dosage form and strength Medicines Level of Dosage form and strength
Healthcare Healthcare
Ranitidine PS,T Tablet 150 mg 21.2.3: Barrier methods
Oral liquid 75 mg/5 ml 21.2.3.1 Condom PS,T As per the standards
Injection 25 mg/ml prescribed in Schedule R
Sucralfate S,T Oral liquidlg of Drugs and Cosmetics
20.2 Antiemetics rules, 1945
Domperidone PS,T Tablet 10 mg 21.3: Estrogens
Oral liquid 1 mg/ml 21.3.1 Ethinylestradiol PS,T Tablet 0.01 mg
Metoclopramide PS,T Injection 5 mg/ml Tablet 0.05 mg
Ondansetron S,T Tablet 4 mg 21.3.2 Levonorgestrel PS,T Tablet 0.75 mg
Oral liquid 2 mg/5 ml 21.4 Medicines used in diabetes mellitus
Injection 2 mg/ml 21.4.1 nsulins and other antidiabetic agents
20.3 Anti inflammatory medicines 21.4.1.1 Glimepiride PS,T Tablet 1 mg Tablet 2 mg
5-aminosalicylic S,T Tablet 400 mg 21.4.1.2 Insulin (Soluble) PS,T Injection 40 1U/ml
acid Suppository 500 mg 21.4.1.3 Intermediate PS,T Injection 40 1U/ml
Retention Enema Acting (NPH)
20.4: Antispasmodic medicines Insulin
1 Dicyclomine PS,T Tablet 10 mg 21.4.1.4 Metformin PS,T Tablet 500 mg
Oral Solution 10mg/5ml Tablet 750 mg
Injection 10 mg/ml 1}s at faiii nlablet 1000 mg (Immediate
2 Hyoscine PS,T Tablet 10 mg and controlled release
butylbromide Injection 20 mg/ml 21.4.1.5 Premix Insulin PS,T Injection 40 IU/ml
30:70 Injection
20.5:Laxatives (Regular:NPH)
.1 Bisacodyl PS,T Tablet 5 mg 21.4.2 Medicines used to treathypoglycemia
Suppository 5 mg
21.4.2.1 Glucose PS,T Injection 25 %
.2 Ispaghula PS,T Granules/ Husk/ Powder
.3 Lactulose S,T Oral liquid 10 g/15 ml 21.5:Ovulation Inducers
20.6: Medicines used in diarrhoea
21.5.1 Clomiphene T EsTablet 50 mg
TR9 2 gert;*Tablet 100 mg
6.1 Oral rehydration PS,T As licensed .
salts
21.6:Progestogens ei
21.6.1 Medroxyproges PS,T Tablet5 mg
6.2Zinc sulphate PS,T Dispersible Tablet 20 mg
teroneacetate Tablet 10 mg
20.7: Other medicines 21.6.2 Norethisterone PS,T Tablet.5 m9
71 Somatostatin Powder for Injection 3 mg 21.7: Thyroid and antithyroid medicines
Section 21:Hormones, other endocrine 21.7.1 Carbimazole PS,T Tablet 5 mg
2 medicines and contraceptives Tablet 10 mg
12.5mcg to 150mcg
21.1:Adrenal hormones and synthetic substitutes
mg
21.7.2Levothyroxine PS,T
Tablet
(Several strengths are
1.1 Dexamethasone ST Tablet 0.5 as
Injection 4 mg/ml available in market such
12.5, 25; 50, 62.5, 75, 88,
1.2 Human chorionic: T Injection 1000 IU yi100, 112 mcg. Theretore
zs1egih bth
gonadotropin Injection 5000 IUU was considered to give a
13 Hydrocortisone PS,T Tablet 5 mg range of available,
Tablet 10 mg :
strengths)
Injection 100 mg/ml
Section 22 Immunologicals
Methylpred- S,T Tablet 8 mng soure
14 nisolone Tablet 16 mg
Incase of these biologicals, irrespective of variation in
same
Tablet 32 mg composition and strengths, all the pröducts of the vaccinea
are consiaer
Injection 40 mg/ml mmunoglobulin, as approved by licensing authority
Tablet 5 mg
included in NLEM. However, considering the soureo
same
ot thesna
.1.5 Prednisolone PS,T technology and other relevant aspects, different products
purposes su as
Tablet 10 mg biologicals should be considered differently for
Tablet 20 mg procurement policy,pricing etc.
T2
21.2: Contraceptives 22.1: Diagnostic.agents
21.2.1: Hormonal contraceptives 22.1.1 Tuberculin,ir : PS T
Tablet 0.03 mg (A)+ Purified Protein
.2.1.1 Ethinylestradiol PS,T (B) derivative
(A) + 0.15 mg
Levonorgestrel 22.2: Sera and immunoglobulins (Liquid/ Lyophillzea
1.2.1.2 Ethinylestradiol PS,T Tablet 0.035 mg (A)+ 22.2.1 Anti-rabies PS,T
1 mg (B)
(A) + immunoglobulin
Norethisterone 22.2.2 Anti-tetanus BS,T: 3
21.2.2 ntrauterine devices immunoglobulin
T Contains 52 mg of 22.2.3 Anti-D S, T
1.2.2.1 Hormone immunoglobulin
releasing IUD Levonorgestrel
PS,T As licensed 22.2.4 Diphtheria PS,T
1.2.2.2 IUD containing antitoxin
Copper
 NATIONALL LIST OF ESSENTIAI MLI 549
Medicines Level of Dosage form and strength
Healthcare Medicines Level of Dosage form and strenyth
22.2.5 Hepalitis B S,T Healthcare
immunoglobulin 25.1.6 Povidone iodine PS,T Drops 0.6%
22.2.6 Human normal T Drops 5%
immunoglobulin
25.2: Antiinílammatory medicine
22.2.7 Snake venom RS,T
antiserunm
25.2.1 Prednisolone PS,T Drops 0.1%
a) Soluble/ liquid Drops 1%
polyvalent 25.3 Local anaesthetics
b) Lyophilized 25.3.1 Proparacaine PS,T Drops 0.5%
polyvalent
25.4 Miotics and antiglaucoma medicines
22.3: Vaccines 25.4.1 Acetazolamide PS,T Tablet 250 mg
al All the vaccines which are under Universal Immunization 25.4.2 Pilocarpine
Programme of India (UIP) will be deemed PS,T Drops 2%
Presently,the UIP has BCG, DPT, OPV, measles, included in NLEM. Drops 4%
Hepatitis B, Japanese
encephalitis & Pentavalent Vaccines. 25.4.3 Timolol e PS,T Drops 0.25%
) The new vaccines, which
have been approved by National Drops 0.5%
Technical Advisory
e given
Group on Immunization (NTAGI)and planned to 25.5 Mydriatics
under UIR will be deemed be included as
to 25.5.1
n UIP These
vaccines are inactivated polio vaccine and when listed
(IPV), Measles
Atropine PS,T Drops 1%
Rubella (MR)
and Rota virus vaccine. Ointment 1%
ncluded in UIP, will also
,
In future, the vaccines which are under consideration if and when 25.5.2 Homatropine PS,T Drops 2%
be deemed included from the 25.5.3 Phenylephrine PS,T Drops 5%
clusion in UIP. These are date of
pneumococcal and HPV vaccines. Drops 10 %
22.3.1: For universal immunisation 25.5.4 Tropicamide PS,T Drops 1%
2.3.1.1 BCG vaccine PS,T 25.6: Ophthalmic surgical aids
2.3.1.2 DPT + Hib + P.S,T 25.6.1 Hydroxypropyl T
Hep B vaccine Injection 2%
2.3.1.3 DPT methylcellulose
vaccine PS,T
2.3.1.4 Hepatitis B 25.7 Miscellaneous
PS,T 25.7.1 Carboxymethyl BS,T
vaccine Drops 0.5%
.3.1.5 Japanese cellulose Drops
PS,T 1 %
encephalitis Section 26: Oxytocics and Antioxytocics
vaccine 26.1: Oxytocics and
3.1.6 Measles vaccine PS,T abortifacient
3.1.7 Oral poliomyelitis 26.1.1 Dinoprostone S,T
PS,T Tablet 0.5 mg
Vaccine Gel 0.5 mg
3.1.8 Tetanus 26.1.2 Methylergo PS,T Tablet 0.125 mg
toxoid PS,T metrine Injection 0.2 mg/ml
22.3.2: For Specific Group ofIndividuals 26.1.3 Mifepristone
3.2.1 Rabies vaccine Tablet 200 mg
PS,T 26.1.4 Misoprostol T
ction 23 : Muscle Tablet 100 mcg
relaxants and cholinesterase inhibitors Tablet 200 mcg
Atracurium S,T 26.1.5 Oxytocin
Injection 10 mg/ml S,T Injection 5 IU/ml
Baclofen S,T Tablet 5 mng njection 101U/ml
Tablet 10 mg 26.2: Medicines used in pre-term
Tablet 20 mg 26.2.1 Betamethasone PS,T labour
Neostigmine S,T Injection 4 mg/nl
Tablet 15 mg 26.2.2 Nifedipine S,T Tablet 10
Section 27:Psychotherapeutic ng
Injection 0.5 mg/ml
Succinylcholine S,T Injection 50 mg/ml medicines
Vecuronium
S,T Powder for Injection 4 mg 27.1: Medicines used In psychotic
27.1.1 Clozapine disorders
Powder for Injection 10 mg T Tablet 25 mg
Section 24 Medicines for neonatal care Tablet 50 mg
Alprostadil Tablet 100 mg
Caffeine
Injection 0.5 mg/ml 27.1.2 Fluphenazine S,T Depot Injection 25
S,T Oral liquid 20 mg/ml 27.1.3 mg/ml
Haloperidol S,T
Injection 20 mg/ml Tablet 5 mg
Surfactant Tablet 10 mg
5,T Suspension for
intratrachealinstillation Tablet 20 mg
Oral liquid 2 mg/
As licensed)
ection25 Ophthalmological Medicines
27.1.4 Risperidone PS,T Tablet 1 mg
5ml
Tablet 2 tng
1 Acyclovir
25.1: Anti-infective medicine 3 Tablet 4 ng
PS,T Ointment 3% Oral liquid 1 mg/ml
Ciprofloxacin PS.T Drops 0.3% 27.2: Medicinesused in mood disorders
Ointment 0.3% 27.2.1 Medicines used
Erythromycin 27.2.1.1 Amitriptyline in depressive disorders
Gentamicin Ps,T Ointment 0.5% PS,T Tablet 10 mg
Natamycin PST Drops 0.3% Tablet 25 mg
Tablet 50 mg
PS,T Drops 5%
Tablet 75 mg

WENINHaNTTT
550 ESSENTIAL MEDICINES AND COUNTERFEIT MEDICINES

Medicines Level of Dosage form and strength Medicines Level of Dosage form and strength
Healthcare Healihcare
27.2.1.2 Escitalopram S,T Tablet 5 mg Section 29 : Solutions correcting water, electrolyte
Tablet 10 mg disturbances and acid-base disturbances
Tablet 20 mg 29.1 Glucose PS,T Injection 5%
27.2.1.3 Fluoxetinee PS,T Capsule 10 mg Injection 10%
Capsule 20 mg Injection 25%
Capsule 40 mg Injection 50%
Capsule 60 mg 29.2 Glucose (A) + RS,T Injection 5% (A) +
27.2.2: Medicines used in Bipolar disorders Sodium 0.9% (B)
27.2.2.1 Lithium chloride (B)
S,T Tablet 300 mg
27.2.2.2 Sodium valproate Ps,T 29.3 Oral rehydration PS,T As licensed
Tablet 200 mg
salts
Tablet 500 mg
27.3 Medicines used for Generalized 29.4 Potassium PS,T Injection 150 mg/ml
Anxiety and Sleep Disordeers chloride Oral liquid 500 mg/5 ml
27.3.1 Clonazepam 29.5 Ringer lactate P.S,T Injection (as per IP)
PS,T Tablet 0.25 mg
Tablet 0.5 mg 29.6 Sodium PS,T Injection (as per IP)
Tablet 1 mng bicarbonate
27.3.2 Zolpidem PS,T Tablet 5 mg 29.7 Sodium chloride PS,T Injection0.9%
Tablet 10 mg S,T Injection 0.45%
27.4 Medicines used for obsessive Injection 3%
compulsive disorders and panic attacks
29.3 Miscellaneous
27.4.1 Clomipramine S,T Capsule 10 mg 29.3.1 Water for PS,T Injection
Capsule 25 mg Injection
Capsule 75 mg
27.4.2 Fluoxetine Vitamins and minerals
30
PS,T Capsule 10 mg
30.1
Capsule 20 mg Ascorbic acid PS,T Tablet 100 mg
Capsule 40 mg (Vitamin C) Tablet 500 mg
Capsule 60 mg 30.2 Calcium PS,T Tablet 250 mg
Section 28 : Medicines acting on the respiratory tract carbonate Tablet 500 mg
28.1: Antiasthmatic medicines 30.3 Calcium PS,T Injection 100 mg/ml
gluconate
28.1.1 Budesonide Ps,T Inhalation (MDI/DPI)
30.4 Cholealciferol PS,T Tablet 1000 1U,
100 mcg/dose
Inhalation (MD/DPI) Tablet 60000 1U
200 mcg/dose Oralliquid 400IU/ml

.
Respirator solution for use 30.5 Nicotinamidea Ps,T Tablet 50 mg
in nebulizer 0.5 mg/ml N i

30.6 Pyridoxine PS,T Tablet 10 mg

Respirator solution for use
in nebulizer mg/ml *i2 9staeniisis bes aa adlet u mg
28.1.2 Budesonide (A)4 PS,T Tablet 100 mg
Inhalation (MDI/DPI) 30.7 Riboflavin
Formoterol (B) i es mcg (A) PS,T Tablet 5 mg
s

100 +6 mcg (B)

pa Inhalation (MDI/DPI)
200 mcg (A)+6 mcg (B)
Inhalation (MDI/DPI) *
sikug
k 400 mcg (A)+ 6 mcg (B)
28.1.3 Hydrocortisone PS,T Injection 100 mg
Injection200 mg.
28.1.4Ipratropium PS,T Inhalation (MDI/DPI)
20 mcg/dose
Respirator solution for use
in nebulizer 250 mcg/ml
28.1.5 Salbutamol PS,T Tablet 2 mg
Tablet 4 mg
Oral liquid 2 mg/5 ml
Inhalation (MDI/DPI)
100 mcg/dose
Respirator solution for use
in nebulizer 5mg/ml
28.1.6 Tiotropium PS,T Inhalation (MDI)
9 mcg/dose
Inhalation (DPI)
18 mcg/dose
MDI- Metered dose inhaler
DPI- Dry Powder inhaler
30.8 Thiamine PS,T Tablet 100 mg
injection 100 mg/ml
30.9 Vitamin A 7
PS,T Capsule 5000 IU
Capsule 50000 IU
Capsule 100000 1U
Oral liquid 100000 IU/ml
Injection 50000 1U/ml
COUNTERFEIT MEDICINES
According to WHO's definition, a drug/medicine
counterteit if it is produced with an,intention to cheat.
can include mis-labelling (including fudging expiry date
no active ingredients, a wrong ingredient, or
ingredient the co
in an insufficient quantity. Both branded al
generic products can be counterfeited (3)
Sub-standard medicines, also called "out of
medicines are authorized medical products thatspeciicat
tail to
either their quality standards
or specifications, or both (
Falsified medical products that deliberately/fraudulenu
misrepresent their identity, composition or
source(
Unregistered/unlicensed medical products
undergone evaluation and/or approval by that al o
the TNauo
 COUNTERFEIT MEDICINES 551
Regional lation Authority for the market in which they are
marketed/distribi or used, subject to permitted conditions Legislation forms the basis for drug regulation. Medicines
national or regional regulation and legislation need to be safe, effective and of good quality in order to
under (4). produce the expected therapeutic effect. Ensuring these
Falsified medical products may contain no properties requires the creaati of competent national drug
active
ngredient, the wrong active ingredient or the wrong amount
regulatory authorities with the necessary human and other
of rect active ingredier They are also commonly found resources to control the manufacture, importation,
o ontain
corn starch, potato starch or chalk. Some distribution and sale of medicines.
sub-
and falsified medical products have been toxin
in
with either fatal levels of the wrong active ingredient Legislation must be complemented with effective law
r other toxic chemicals. Anti-malarials and antibiotics are
enforcement. Governments need to develop strategies to
the most commonly reported sub-standard and reduce corruption and criminal activity and promote
amor
falsified medical products. Both generic and innovator intersectoral co-operation between regulatory authorities,
medicines can be falsified. An estimated 10 per cent police, customs services and the judiciary to effectively
medical control the drug market and enforce drug regulation.
Droducts in low and middle-income countries is sub
standard or falsified. These products contribute to
antimicrobial resistance and drug-resistant infections (4). QUALITY CONTROL IN
Unregulated websites, social media platforms and DRUG SECTOR IN INDIA
smartphone applications can also be direct conduits of sub-
standard and falsified medical products. Risks to consumers Central Drug Standard Control Organization (5
are increased when they obtain medicines from unlicensed
The quality control of the drugs marketed in the country
and unregulated sources. Consumers should be cautious of
is regulated under the Drugs and Cosmetics Act, 1940 and
the following (4);
Drugs & Cosmetics Rules, 1945. The Central Drugs
1 spam email advertising medicines; Standard Control Organiza (CDSCO), in the Directorate
2. lack of authenticity or no verification logo or certificate; of Director General of Health Services, along with Drug
3. spelling mistakes and poor grammar on packaging; Control Organization in the States are responsible for safety,
4. websites that do not display a physical address or
efficacy and quality of drugs, their import, manufacture,
distribution, sale and standards.
landline; and
websites offering prescription only medicines without a The CDScO at the Centre is headed by the Drugs
prescription.
Controller General (India), in the Directorate of Director
General of Health Services, under the Ministry of Health
ldentifying a sub-standard or falsified medical and Family Welfare. The Drug Control Organization in the
product States is generally headed by the State Drug Controllers
appointed by the State Governments.
Some falsified medical products are almost visually The main functions of the CDSCO include control of the
identical to the genuine product and very difficult to detect.
However, many can be identified by (4):
quality of drugs imported into the country, coordination of
the activities of the States/UTs Drug Control Authorities,
examining the packaging for condition, spelling mistakes approval of new drugs proposed to be imported or
or grammatical errors; manufactured in the country, laying down standards and
Checking the manufacture and expiry dates and ensuring regulatory measures and acting as the Central License
any details on the outer packaging match the dates Approving Authority in respect of whole human blood and
shown on the inner packaging; its products, large volume parenterals (IV fluids), sera and
vaccines and r-DNA products. Quality of cosmetics
ensuring the medicine looks correct, is not discoloured, manufactured and marketed in the country are also
aegraded or has an unusual smell;
regulated under the Drugs and Cosmetics Act.
ucussing with your pharmacist, doctor or other The CDScO has a network of six Zonal Offices located at
edithcare professional as soon as possible if you suspect Mumbai, Ghaziabad, Kolkata, Hyderabad, Ahmedabad and
ue product is not working properly or you have suftered Chennai, six sub-zonal oftices and 16 port offices
an adverse reaction; and
responsible for ensuring quality of imports and
Porting suspicious medical products to your National 7 laboratories. The Zonal Officers inspect the drug
Medicines Regulatory Authority. manufacturing units, blood banks and approved drug testing
WHO launched the international medical laboratories, either jointly with State Drug Control
2006, Authorities or independently, and deficiencies observed
2012 Anti-Counterfeiting Task Force (IMPACT) and in
2013, WHO and during these inspections are invariably brought to the notice
Monitor launched the Global Surveillance to report of State Drug Control Authorities. The port offices monitor
encourage countries
incidence System to products in a import and export of drugs.
structu of sub-stan and falsified medical
develop a more
accurat dhd systematic format, to help References
ate and validated assessment of the problem.
WHO (2005), Tech. Rep. Ser. No. 933, The Selection and Use of
easures for combating unterfeit medicines so far have 1.
Essential Medicines.
and
uded: actions talken by drug regulatory authorities
enforcement 2
3.
ovt. of India (2015), NationalList of Essential Medicines, 2015.
Operation initiatives between different law WHO (2006), Fact Sheet M, 275, Counterfeit Medicines.
agencies: providing
simple, erpretable and cheap 4. WHO (2018), Fact Sheet, Sub-standard and falsified MedicalI
coordinatinginternational Products, 31st Jan. 2018,
urveillan authenticity; and educating 5. Govt. of India (2019), Annual Report 2018-19, Ministry of Health
patients
ents Or fake and sub-standard drugs; and Family Welfare, New Delhi.
and healthcare workers.
 SUSTAINABLE DEVELOPMENT GOALS
Each year about 1.25 million people die from road traffic
injuries and another 20-50 million people sustain non-latal
injuries as a result of road iraffic collisions or crashes. Road
traffic injuries are among the top 10 causes of deaths
globally and the leading cause of death for people in l5-29
years age group. Homicide and collective violence accounts
for around 10 per cent of global injury related deaths. Four
fifths of homicide victims are men and 60 per cent of victims
are of 15-44 years age group (1).
A proposed indicator for SDG target 16.1 is conflict death
per lac population. In 2015, it is provisionally estimated that
1,52,000 people were killed in wars and conflicts,
corresponding to about 0.3 per cent of global deaths (2)
New indicators (3)
New indicators for SDGs have been added in the year
2020. They are as follows:
SDG 2.2.3 In 2016, the global prevalence of anaemia
among women of reproductive age was 32.8 per cent
(compared with 30.3 per cent in 2012). Applied to the
latest UN population estimates, that equated to 615.8
million women with anaemia. The rates of anaemia were
highest in the WHO South-East Asia (45.8 per cent
Eastern Mediterranean (39.8 per cent) and African (39.00
per cent) regions.
SDG 3.6.1: Human papillomavirus (HPV) is the most
common viral intection of the reproductive tract, and
can cause cervical cancer. The vaccine targettingg
9-14 years-old girls is now offered in 90 countries, but is
yet to reach the poorest countries where the risk of
cervical cancer is the greatest. Global coverage for a full
course of HPV vaccines increased from 3 per cent in
2010 to 12 per cent in 2018.
SDG 3.b.3: Based on a sample of 25 countries,
surveyed between 2008 and 2019, on an average only
22.4 per cent of health facilities provided an available
and affordable (accessible) core set of relevant essential
medicines for treatment, prevention and management o
acute and chronic, communicable and non
communicable diseases in primary health care settings.
A lot of variation in access to medicines is observed
between these 25 countries. Specifically, in 28 per cent
of countries none of the facilities provided accessible
medicines.
SDG 3.d.2 By rendering medicines ineffective,
antimicrobial resistance undermines the treatment of
Common infections and increases the risk of spread to
others. After the launch of the Global Antimicrobial
Resistance Surveillance System (GLASS) in 2016, as of
21st April 2020, a total of 91 countries and territories
have been supported to enroll into the system and
participate in the annual data call on antimicrobial
resistance and consumption. Data on the overall
prevalence of antimicrobial- resistance pathogens are
currently limited, but completeness and
representativenes of the data have continuously
increased at every GLASS data call. The last data call
run in 2019 gathered frequency of antimicrobial resistant
pathogens in common acute bacterial infections,
including bloodstream infections from 66 countries and
territories. Monitoring AMR will help inform control
strategies and actions to mitigate impact on the
population such as intorming the treatment protocols,
enhancing Infection Prevention and Control (IPC) and
water, sanitation and hygiene (WASH) in health care
facilities, increasing the availability of "Arson
ssgroup
antibiotics, as wel as continuous improve
Of
surveillance capacities. Establishing AMR surveillance
systems will also builkd country capacity monitor
respond lo risks irom emerging pathogens. Or and
SDG 6.2.2(b) : Proportion ot population using
a hand.
washing facility with soap and water.
GPW13 indicators
- Number of cases o poliomyelitis caused by wild
poliovirus.
Age-standardized prevalence ol raised blood
among persons aged 18+ years (defined systolic
blood pressure of 140 mmig and/or diastolic hlo
pressure >90 mmHg) and mean systolic blood pressuro
Prevalence of obesity.
Health system
Health system strengthening is a core focus of the SDGs
This is reflected by the tact that universal health care (UHC
is central to the overall health goal as set out in SDG
declaration and is assSIgned a special target (3.8). In order to
move towards the UHC goal, country health system needs to
be strengthened as well as adapted to meet the shifting
health Priorities associated with demographic and
epidemiological transition, rapidlly developing technologies
and changing public expectations. lable 8 shows the targets
and indicators linked to health system.
TABLE 8
Selected SDG targets and proposed indicators linked to
health systems, by type ot indicator
lype or SDG Proposed indicator
indicator target
Coverage/l 3.8 UHC index: tracer indicators on service
financial access (hospital access, health workforce
protection density by specitic cadres, access to
medicines and vaccines, IHR capacitiesj
3.8 UHC: financial protection (catastrophic and
impoverishing out-of-pocket health spendingS
System 3.6 Access to medicines and vaccines
3.b Research and development on health issueS
that primarily affect developing countries,
including official development assistanoe (UR
3.c Health workforce density and distribution
3.d IHR capacity and health emergency
preparedness
17.18 Data disaggregation
17.19 Coverage of birth and death registration,
ot regular population census.
completion
Source: (2)
ACcess to atfordable medicines and vaccines wn
sustainable basis is an indicator to SDG target 3.b
Ocusses on support for research and development
and
and vaccmeS
the atfordability of medicines
Communicable diseases and non-communicabe S
A
that primarily affect developing countries.
indicator under SDG target 3.b aims to capture the ieve
research and development investments.
see Solel
The transition from MDGs to SDGs cannot be a longe
as exchange of a short list of goals and targets lorMDGs, *
one. The SDGs are fundamentally different to tne ncC
is the political context in which they have
eDGs had
and as in which they will be implemented. The Pi
 SOSTAINABILE DEVELOPMENT GOALS 559
more or less Singular purpose. They were with disabilities,
ad omy, older people, children, persons - riK being
istent aievement of improved human development refugees
about.
oulcome
marily in terms ot poverty, education and
nt
nous ven narder.
people, migrants and
A large-scale multilateral
response is needed to
resources they need
developing countries.hey were closely Cnsure that developing countries have
Realn with aid-spending.he SDGs in the words of to protect household and businesses (
ateu are "integrated and indivisible, global in nat
as$OCiated
Goals (6)
aclaratoallu applicable".
universal
applicable". ItIt is
is rrelevant to all countries and India and Sustainable Development
nd
bout developing countries.
As the MDGs reached their December
2015 deadline, the
tuMDGs were about limited set of human ot Sustainable Development
Goals were deing
hile
ment targets, the
SDGs cover the economic set by India also. There is
now a remarkaoie
the priorities tor tne
adapted
evelopntal and social pillars ot sustainable development Vergence of vision underlying
vironmer
government India.
strong tocus
on uity; expressed more frequently it proposed SDGs and those of the new to end poVerty
a nhrase "no one will be left
ith behind". Duilding on the MDGs, the SDGs propose behind, wnil
all forms, leaving no one
oral health targets tolloW on from the
unfinished MDG and deprivation in Socially and
economically,
da and many are derived irom World Health Assembly making development
government ot India nas
n5olutions and related Action
Plans (1). enironmentally sustainable. The Sabka vikas
also adopted the principle of Sabka Sath pledge thar
development for all"), with
Gustainable development goals and COVID-19 tOgether with all, poor. ne
progress the ne irst claim on development belong to the
Refore the COVID-19 pandemic, the in
government is calling for improved sanitation, healtn
ement of SDG remained uneven and were not on and dignity for all,
education, financial inclusion, security
meet the goals by zU50. Some gains were visible:
especially women. The priority is improving environmenta
rk to
the share of children ana youtn Out of school had
fallen; the biosphere by
was in decline: aevelopment with respect to water, air, soil and as an
incidence ot many cOmmunicaole diseases treating challenges of climate change adaptation
access to safely managed drinking water had improved; and opportunity rather than a problem.
wOmen's representation in leadership roles was increasing.
can progress towards sustainable development
in
the number o people sutfering from food ndia
time,
health if health is high on the national and state agenda.
At the same
insecurity was on the rise, the natural environment
continued to deteriorate at an alarming rate, and dramatic his requires high political committment. India should invest
levels of inequality persisted in all regions. Change was still in public health and finish agenda through further
required. improvement in maternal and child health, confronting
not happening at the speed or scale
neglected tropical diseases, eliminating malaria, AIDS and
Now, due to COVID-19, an unprecedented health, hepatitis and increasing the fight against TB. For all these
Chalenges. the programmes and interventions need to
is threatening lives and givve
economic and social crisis
livelihoods, making the achievement of Goals even more quality services, with implementation ot universal health
challenging. The death toll continues to climb, with almost care. India needs to build robust health system in all aspects
no country spared. Health systems in many countries have and strengthen both the urban and rural components, With
been driven to the brink of collapse. The livelihood of half primary health care at its centre. More involvement of
the global work-force has been severely affected. More than private health sector is vital. India needs to develop a strong
l.6 billion students are out of school, and tens of millions of system for monitoring, evaluation and accountability.
people are being pushed back into extreme poverty and
The goal of sustainable development cannot be achieved
hunger, erasing the modest progress made in recent years.
could reverse the progress in reducing maternal and child
t globally without India, and the world will be watching how
India will implement its new strategic directives.
deaths, COVID-19 has disrrupted childhood immunization
eforts globally with potentially deadly consequences. 1he References
Cal care tor the people with non-communicablethediseases 1. WHO (2015), Health in 2015 from MDGs (Millennium Development
aected as many people are not receiving health Goals) to SDGs (Sustainable Development Goals).
VICes and medicines they need. Same is the case of 2. WHO (2016), World Health Statistics, 2016, Monitoring Health for the
communicable diseases like tuberculosis, malaria and Hiv. SDGs.
3. WHO (2020), World Health Statistics, 2020, Monitoring Health for the
Although the novel coronavirus affects every person and
SDGs.
omnunity, it does not do so equally. Instead, it has exposed 4. UNICEF (2019), State of World's Children, 2019..
u exacerbated existing inequalities and injustice n 5. United Nations (2020), The Sustainable Development Goals
anced economies, fatality rates have been highest Report-2020.
ng marginalized groups. In developing countries, the 6. UN-India (2015), India and the MDGs: Towards a Sustainable Future
Jor All.
Vunerable - including those employed in the intorma
:
 TRENDS 561
WORLD POPULATION
TABLE 3
developed and
Birth and death rates in selected
2020
U.S.A India developing countries in mid rate
331 Death
1400.2 Country Birth rate

India 20
mdonesia Bangladesh 21
271 Pakistan 28
Sri Lanka 15
10
Thailand
18
Myanmar
21
China Nepal
10
1439 China 11
7
Japan
Pakistan 9
Singapore 9
220 11
UK
12
Brazil USA
212 (2)
Source: the first time
rate fell below 30 for
The world's birth 18.2 during
Nigeria
1975 and had declined to about reflected
206 around world the decline
Bangladesh
mid-2019 (3). In most of the global trend towards smaller
rates and a and
Russia Mexico falling birth examples are Singapore
169
145 128 families. The outstanding years, the birth rate fell from
millioon Thailand. In Singapore, in 50 2020; and, in Thailand trom
Population in 1970 to 9 in
23 per thousand in
37 per thousand to 10
during the same period.
FIG. 1

world (mid-2020) TABLE 4

Ten most populated countries of the and death rates in
Reduction in the birth1990-mid-2020
Source: (2) selected countries,
gap of Death rate
third in the world after
India, there is a yawning countries.
Birth rate
1990 mid-2020
two
population of these population is Country 2020
1990
1049 million between the
has estimated that world's 21 10 5
The United Nations l1.1 per cent in the year 2019. Bangladesh 35
13
growing at an annual
rate of 38 21
million), Nepal 6
countries of SEAR, i.e. India (1400 are 31 20 11
Three Bangladesh (169 million) India 15 7 6
Indonesia (271 million), and world. At Sri Lanka 21
most populous ten countries of the China. 19 10 8
among the of Thailand
is second to that 9
present India's population population will reach 1.53 Singapore 18 7
According to UN projections
India's population 23 10
will be the highest China 11 6
billion by the year 2050, and increase in 40 28
of population Pakistan
country in the world. The trend Table 2.
South East Asia Region
countries is as shown in Source (2) fertility decline
these countries, key factors in growth,
In all government attitudes towards
TABLE 2 included changes in availability of
increased
in increase of population of SEAR countries the spread of education, of services offered through
rends
(in million) contraception and the extension change
planning programmes, as well as the marked
mid-2020 family
1991 in marriage
patterns.
Country declined worldwide over the las
843.9
1,400.0 Death rates have also rate declined from 11.0 (betweer
India
118
169.8 decades. The global death population during 2018,
1975-1980) to 7 per thousand rate of the
cent. The decline in the death from 14.
Bangladesh 0.7
1.5 of 23 per
Bhutan 271.7 reduction been more marked,
187.7 South-East Asia Region has
Indonesia 0.5 population.
0.221 to 7.0 per 1000 crud
Maldives
42.5
54.7
countries with a relative young population, mortalit
Myanmar 30.0
In
attected by intfant and child
19.6 death rates are mainly maternal and child health service
Nepal
17.4
21.9 With improvement in expanded programme
Sri Lanka 66.5 successful implementation of the and acute respirato
Thailand
56.4 immunization, diarrhoeal diseasewell as with the control
programmes, as
infection control reducti
Source (2, 3) infectious diseases, there has been marked
other reflected in
1

and child mortality rates, which are

Birth and in infant
death rates death rates in selected declining crude death
rates.
Countdring contrasts in birth and
are
ountries 3.
as shown in Table
 DEMOGRAPHIC TRENDS IN INDIA 563
on has been steadily increasing Demographic
India's 1921 is called the "big divide" becausesince cent to the nation-wide increase in population.
year timing and s1ze of
1921.The people added to the population duringthe Ourcomes in these states will determine the
olute number or
stabilization.
on the increase since 1921 (Table Population at which India achieves population
cade has been 6).
each population is currently increasing at the rate
India's of Age and sex composition
year. population is as
lion each he age-sex composition of India's
a'sDopulation numbered 238 million in 1901, doubled years male
shown in Table 8. In the age group 0-14 whereas
ye.ars 439 million (1961); doubled again, this time in population is about 1.2 per cent more than female,
60 30 years to reach 846 million by 1991. It crossed group 60+, percentage of female population is
only 1ark on 1l May 2000, and is projected to reach theperage
cent more than male population. The proportion or
1 bilion
billion by the year 2050 This will then make India the 0. in rural
Population in the age group 0-14 years is highercent), 1or
1.53 per
populous country in the world, surpassing China. areas (2/.5 per cent) than in urban areas (22.6
most
Withthe
division ofsome states the rank of most populous both male and female population (7).
age is
states have
changed. Table 7 shows the ten most populous The proportion of population below 14 years of
of elderly in the
statesin the country by rank. is seen that Uttar Pradesh
It showing decline, whereas the proportion
about 231.425 million people, Maharashtra to continue in the time to
first with country is increasing. This trend is
a
will impose
o$Cond with 128.711 million people and Bihar comes Come. The increase in the elderly population
health services in
Ki with 108.377 million people. These ten states account greater burden on the already outstretched
fnr
about 71 per cent of the total population of India (7). the country.
TABLE 7 TABLE 8
Ranking of most populous states Per cent distribution of estimated population
by projected population size 2020 by age and sex. India (2018)

Population Per cent to total Age Population percentage

Rank State 2020 population of India group Total Males Females

1 Uttar Pradesh
Maharashtra
(000)
231,425
128,711
2020
16.7
9.0
0-4
5-9
10-14
8.0
8.6
9.3
, 8.2
Lwjte8.8
9.5
7.8
8.4
9.1
2
. Bihar 108,377 7.8 15-19 10.2 10.4 10.0
4. Andhra Pradesh 90,949 6.5 20-24 10.8 10.5 11.0
. Madhya Pradesh 82,134 5.9 25-29 10.1 i7 9.9 10.2
Rajasthan 76,759 5.5 30-34 8.4 8.5 8.4
Tamil Nadu 70,617 5.0 35-39 7.3 7.2 7.3
8. Gujarat 65,532 4.7 40-44 6.2 6.2 6.2
9. Karnataka 64,410 4.6 45-49 5.3 5.3 5.3
10. Odisha 43,732 3.1 50-54 4.2 4.3 4.2
55-59 3.5 3.4 3.6
Source: (8) 1
60-64 3.0 2.9 3.0
has been estimated that with current trends, the
It
2.1 2.1 2.2
population in India will increase from 1.210 billion to
65-
1.4 billion during the period 2011 to 2026. There is a
70--74 1.4 1.3 1.5
75-7 0.9 0.8 0.9
Substantial difference in total fertility rate in between and within
80-84 0.5 sr ( 0.4 0.5
states. At one end of spectrum are southern states like Kerala, 85+ 0.3 0.2 0.3
lamil Nadu, Karnataka fertility
andAndhra Pradesh with total 100.0 100.0
rateat or below replacement levels. At the other end are high Total 100.0
ertlity states like Uttar Pradesh, Chhattisgarh, Uttarakhand, Note: Total may not add upto 100 due to rounding off.
Hajasthan, Jharkhand, Bihar, Madhya Pradesh and Orissa,
wIth an estimated
total fertility rate of more than 2.2. Source: (7)

Ihe Government of India has categorized states Population pyramid

cording to total fertility rate (TFR) level into very high- Population pyramid is also known as "Age and Sex"
us more than or equal to 3.0), high-focus (more than 2. pyramid. It is a graphical representation of the age and sex of a
ess
Categories.
than 3.0) and non-high focus (less than or equal
The states categorized as very high-focus
population. It shows the distribution of ages across a
population divided down the center between male and female
and high focus
are as follows (9 members of the population. The graphic starts from the
TFR 2.2-3.0 youngest at the bottom to oldest at the top. It is called a pyramid
Assam-2.3, Dadra & Nagar
Haveli-2.3, Mizoram-2.3, because when a population is growing (there are more babies
Chhattisgarh-2.5, Jharkhand-2.6, being born then there are people dying) the graphic forms the
Manipur-2.6, Rajasthan-2.7, shape of a triangle. A population pyramid can be
used to
Nagaland-2.7, Madhya Pradesh-2.8 compare difference between male and female population of
an
TFR more area. They also show the number of dependents and general
Or equal
than Bihar-3.3, Uttar Pradesh-3.1 and structure of the population at any given time (10).
to 3.0 Meghalaya-3.0
t
is matter of
attainr concern that these states will delay the
Fig. 2 shows age and sex pyramid of India
Switzerland. The pyramid is typical of developing and
highferssot replacement level of fertility in India. These countries,
with a broad base and a tapering top.
ates are anticipated to contribute about 50 per
 PLANNING
DEMOGRAPHY AND FAMILY
564 SWITZERLAND
INDIA Population 8.65 million (mid-2020)
Population 1390 million (end-2020)
100
D0 95-99 Male Female
Male Female
90-94
85-89 on.s4
S0-84
0-74
0-74
65-69
5-6 60-64
60-64 5-59
55-59
S9-54
S0-54
43-4
4044
36.39 3539
-34
30-34
25-29
25.29
0-24
4
15-19
15-19
10-14

4 6% 6
FIG. 2
Percentage distribution by oge of the population of India and of the population of Switzerland.

Sex ratio Sex rolio ot birth: Sex ratio at birth can be alfected by
Sex ratio is defined as "the number of females per 1000 sex-selectivity at birth. The sex tatio at birth for India for the
males. One of the basic demographic characteristics of 1he year 2016-2018 has been estimated at 899. It varies from
population is the sex composition, In any study of 900 in ural areas to 897 in urban areas. Among the bigger
populafion, analysis of the sex composition plays a vilal stales, 1he sex ratio at birth varies from 958 in Chhattisgarh
role. The sex composílion of the popuiafion is affected by 840 in 1laryana. In the rural arcas, the highest and lowest
the differentials in mortality conditions of males and sex tatio at birth are in the stales of Chhattisgarh (976) and
females, sex selective migration and scx ralio at birh. Haryana (840) respectively. The sex ratio in urban areas
"Female deficit syndrome" ís considered adverse because of varies from 968 in Madhya Pradesh to 810 in Uttarakhand.
$ocial implications. A low sex tatio indicales strong Table 10 shows tlhe variations of sex ratio at birth by
male-
child preterence and consequent gende inequilics, neglect residence in the bigger states of the country.
of the girl child resulting in higher morlality at younger age,
female infanticide, female foeticide. higher maternal TABLE 10
mortality and male bias in enumeration of populalion. EAsy
Sex 1atio at birth by residence in India 12016 2018)
availability of the sex determinatíon fests and abortion
services may also be proving to be catalyst in the process, No. of Females per 1000 males
which may be further stimulaied by preconception Bigger stetes
sex Total Rural Urban
selection 1acilities.
The trends in the sex ratio in the country irom Andhra Pradesh 920 930 898
1901 Assam 925 905
onwards are as shown in Table 9. 927
Bihar 895 896 883
TABLE 9 Chhattisgarh 881
958 976
CX Tati0 In na1a Delhi
844 960 841
YCar Females per 1000 males
Gujarat 866 865
866
Haryana 847
1901 840
Himachal Pradesh 891
1911 932
4 Jammu & Kashmir
1921 927 930 917
955 Jharkhandd 888
1931 Karnataka 923 932
950 924 881
1941 949
945 Kerala 947
1951 957 967
946 Madhya Pradesh
925 914 968
941 Maharashtra 881
1971 930 Odisha 880 878
981 933 940 891
934 Punjab 908
1991 927 890 878
Rajasthan 860
2001 933 Tamil Nadu 871 874
2011 908 903
Telangana 913
Source 901 918 875
Ottar Pradesh 934
880 865
The sex ratio in India has been generally Uttarakhand 810
women, i.e., the adverse to West Bengal 840 851
number of women per 923
generaly been less than 1,000. Apart from 1,000 men has ind
941 947
women, the sex ratio has being adverse
also declined over the decades. to
897
899 900
Source: (7)
 URBANIZATION 565
Child sex ratio
(0-6 years) Census 2011 marks
erable fall in child sex ratio in the age group of
a advantage is taken of the demographic transition with high
0-6 economic growth rates (13).
consid
yeas hashas
reached an all time low o1 914 since 1961.
been 13 points irom 927 1o 914 for the country he term "demographic burden" is used to connote the
The a
2001 to 2011. In Tural areas, the fall has been ncrease in the total dependency ratio during any period ot
dutant -15 points irom 934 10 919 and in urban areas it tme, mostly caused by increased old age dependency rati0.
is an inevitable consequence of demographic transition,
Sen 4 points from 9ub to 902 over the decade (6). his
and the country has to face this problem sooner
oor
a5
Dependency ratio later (13).
The proportion of persons above 65 years of age and Density of population
years o age are considered to be
children belowo
Aonendant on he One of the important indices of population concentration
economically productive age group
(15-64 years). The ratio of the combined age groups 0-14
1S
the density of population. It is the ratio between (total)
OATSplus 65 years and above 10 1he 15-65 years age group population and surface (land) area. This ratio can be
Teferred to as the total dependency ratio. It is also referred calculated for any territorial unit for any point in ume,
as the societal
depending on the source of the population data (13). In the
1o dependency ratio and reflects the need
for a society 1o provide 1or their younger and older indian census, density is defined as the number of persOns,
living per square kilometre. The trends of the density in the
population groups. he dependency tatio can be subdivided
i

country from 1901 onwards are as shown in Table 11. For

into youns age dependency Tatio (0-14 years); and old
ratio (65 years and more). These ratios the year 2020 the density of population per sq. km. in
age dependency
India was 464.
are, however, relatively crude, since they do not 1ake into
consideration elderly or young persons who are employed
TABLE 11
or working age persons who are unempioyed, I1 is
given by
the tormula:
Density of population in hdia 1901-2011
Children 0-14 years age + Year Per sq.km
Total
Population more than 65 yeats of age 1901 77
dependency x100
tatio Population of 15 to 64 years 1911 82
1921 81
For India, 1he dependency ratio for the year mid-2020 is 1931 90
calculated as: 1941 103
% of population in 0-14 years age group - 26.2 per cent 1951 117
% of population above 65 years of age 6.6 per cent 1961 142
%of population in 15-64 years age group - 67.3 per cent 1971 177
1981 216
Total
dependency
26.2 +.0x1000 1991 267
67.3 2001 325
ratio
2011 382
t 48.736 per cent
Source:(0)
he young age dependency ratio is 26.2 per cent,
and old age dependency ratio is 6.6 per cent for the year
mid 2020 (12). Urbanization
By definition, urban population is the number of persons
For international comparison, the child, old and total residing in urban localities. The delinition of urban locality
pendency ratios are used to study 1he dependency burden varies from country to country. In Indian context, the urban
the population. The total dependency ratio tends 1o areas are the "Tons (places with
crease in the earlier stages of development when rapid municipal area committee, town municipal corporation,
in fertility reduces the child population more than
committee, notified
cine
ne increase in the older persons, but subsequenuy
area committee or cantonment board); als0, all places

ase in older persons far out-weighs the decline in the a

having 5,000 or more inhabitants, density of not less than
1,000 persons per square mile or 390 per square kilometre,
population. There is a shift from child dependency 10 pronounced urban characteristics and at least three fourths
ihge dependency, as fertility declines and life expectancy of the adult male population employed in pursuits other
incteases.
than agriculture" (13).
The especially the
child d decline in dependency ratios, The population in lndia continues to be predominantly
ratio, has been identified to be a key iactor rural with agriculture as the main occupation
underthaency for the-
democr pa economic development. he term najority of the people.
Qemographic the
depend bonus connotes the period when As per population totals for the year 2019,
n fo cy ratio in a population declines because of decline the urban.
opulation stands at 471.828 million (34.5 per
Mumbai is the highest populous city with 12.69 cent)
lonoe until starts to
it rise again because of increasing
ertili
ast, tho
ns period depends on the pace of decline in
Ol a population. If the switch to small 1amilies is
followed by Delhi 10.927 million, Bengaluru
with 5.104 million, Kolkata 4.631 million is
millior
comes thirC
deve emographic bonus can give a considerable push t10 fourth ane
Chennai (4.328 million) is tith. Fig. 3 indicates the
in health care and education for level o
Skdevelopn investment are made during this period, maximum urbanization in the country (11).
 PLANNINNG
DEMOGRAPHY AND FAMILY
568 with her husband is exposed to the sk
15 and living till 45 birth
has continued to
increase 30 years, and may give to
Lite expectancy at birth1950-1955, the combined lite of pregnancy for achieved.
children, but this maximum is rarely
globally over the years. For was 46.5 years. Five
15
factors. The higher
fertilie
expectancy at birth for both sexes Fertility depends upon several ad
years an increase of 22.5 to universality of marriage, lower
decades later by 2008, it was 69 marked in less developed in India is attributed poor level of living, limitod
m
years. The increase has been more marriage, low level of literacy, ways of life. Natian:
developed regions (15). and tradifional
regions of the world than in the use of contraceptives Conducted in India uring
Most countries in the world
exhibit a sex differential in Family Health Survey-4 fertilit
mortality favouring women
females live longer than males
- 2015-2016 provides some detailed information of
trends, as shown in Table 16.
as shown in Table 14 and 15.
people are living
Trends in life expectancy show that TABLE 16
a long life in good health,
longer, and they have a right to Total fertility rate by selected background
characteristics
disability. Health policy makers
rather than one of pain and demographic pattern (2015-16)
thus need to recognize this changing diseases associated National Family Health Survey-4
of
and plan for prevention and control
Total fertility rate
with old age. Background characteristics
birth in India
Tables 14 and 15 present life expectancy at
Japan leads in life Residence
and those in selected countries. 81 and 87 years 1.75
expectancy for both males and females, Urban
2.41
respectively for the year 2020. Rural
Education
TABLE 14 No education
3.06
2.43
Expectation of life at birth, years in India <5 years complete
2.38
FemalesS
5-7 years complete
Year Males 8-9 years complete 2.19
1.99
1901 23.63 23.96ce 10-11 years complete
1.71
22.59 23.31 12 or more years complete
1911
1921 19.42 20.91 Religion
Hindu 2.13
1931 26.91 26.56 2.61
Muslim
1941 32.09 31.37 1.99
Christian
1951 32.45 31.66 Sikh 1.58
1961 41.89 40.55 Buddhist/Neo-Buddhist 1.74
Jain 1.20
1971 46.40 44.70
Other 2.57
1981 54.10 54.70
1991
Caste/tribe
59.70 60.90 2.26
Scheduled caste
2001 63.90 66.90 2.48
Scheduled tribe
2011 64.00 67.00 Other backward class 2.22
Others 1.93
Source: (6) 2.81
Don't know
Wealth index
TABLE 15 3.1
Lowest
Expectation of life at birth, years, in selected countries 2020 Second 2.45
2020 Middle 2.07
Developing Developed 2020
countries Fourth 1.84
Male Female countries Male Female
Highest 1.54
Nepal 67 70 UK 79 83
Bangladesh 71 74 USA Total 2.18
76 81
Myanmar 64 69 Sweden 81 85 Source: (18)
India 68 70 Switzerland 82 85
Sri Lanka 74 80 Russian Federation 68 Some of the factors which have engaged attentio
78
Thailand 73 80 Japan
demographers since long are discussed below.
81 87
Pakistan 67 71 Singapore 81 85 1. Age at marriage
Source (2) The age at which a female marries and enters the
reproductive period of life has a great impactO fertility
itu on a
The Registrar General of India collected data on fertilit
FERTILITY the
national scale and found that females who marry ore
than
By fertility is meant the actual bearing of age of 18 gave birth to a larger number of children
children. Some rapher
demographers prefer to use the word natality in those who married after (19). In India some demon
fertility. A woman's reproductive place of have estimated that if marriages were postponed from
period is roughly from age of 16 to 20-21, the number of births would deecrease
by
15 to 45 years a period of 30 years. A
woman married at 20-30 per cent (19).
 FERTHLITY RELATED STATISTICS 571

Birth and death rates

TFR CBR components of
The birth and death rates are important
in India are
Jndia
20.0 population growth. The birth and death rates whereas
that
Uttar
2.9
25.6 shown in Table 18. A look at Table 18 shows in 1951
Pradesn the death rate has considerably declined
from 274
in 2018, the
Bihar 26.2
to an estimated 6.2 per thousand population
2.5 in 1951 to an
Rajasthan 24.0 birth rate has declined niggardly from 39.9
Madhya 2.7 24.6 estimated 20.0 per thousand in 2018.
was to
The Fifth Five Year (1974-79) Plan's objective
Pradesh
Haryana 20.3
thousand at the beginning of
2.2 reduce the birth rate from 35 per During 1979-84, the
Assa
21.1
the Plan to 30 per thousand by 1978-79.
thousand with no
Gujarat 19.7 birth rate was stagnating around 33 per birth rate showed
19 18.2 obvious decline. During 1990, however, the declining to 26.4
a slight decline, to an estimated 30.2, further
Odisha
that birth and
Himachal
Pradesh
15.7
by the year 1998. The current picture indicates
Maharashtra 15.6 death rates are both declining in India.
Punjab 14.8 TABLE 18
West 5 15.0 Birth and death rates in india
Bergal
1.7 Birth rate Death rate
Karnataka 17.2 Year
Andhra 16.0 39.9 27.4
Pradesh 1941-1950 22.8
1.6 14.7 1951-1960 41.7
TamilNadu 41.2 19.0
.7 1961-1970 15.0
Kerala 13.9
1971-1980 37.2
33.9 12.5
Jharkhand
2.5 22.6 1981 9.8
1991 29.5
ahansgan
22.5
28.3 9.0
1995 9.0
Delhi 1.5 14.7 1998 26.8
26.1 8.1
J&K 1.6 15.4 999 8.1
2002 25.0
16.9 24.1 1.5
Telangana 2004
23.5 7.5
Utarakhand 1.8 16.7 2006 7.4
2008 22.8
25 30 22.1 7.2
10 15 20 2010
21.6 7.0
FIG. 5 2012 7.0
2015
20.0
fertility rate (2018) 64
Crude birth rate (2018) and Total 2016 20.4
for major states 20.0 6.2
2018
Source: (7, 25)
age Source: (7)
indicators and
Recent estimates of the fertility India like other developing
Specitic fertility rates in India are given
in Table 17. HIGH BIRTH RATE
of a high birth rate and a
countries is faced with the dilemma vicious circle, not easy to
TABLE 17 declining death rate. This is a
Fertility indicators of India, 2018 rate are (1) Universality of
break. The causes of high birthuniversal and sacramental.
Total Rural Urban marriage Marriages are
Age group sooner) gets married and
Indicators
13.5 8.4 Everyone, sooner or later (usually individual's economic
The
Age-specific fertility rate 15-19 12.2
135.9 91 .5 participates in reproduction. are seldom a pre-requisite to
20-24 122.9 security or emotional maturity
146.4 160.1 119.1 : Marriages are performed
-29
94.7 101.3 81. marriage. (2) Early marriage 60 per cent of the girls aged
30-34 30.2 early. Data indicate that about
35-39 36.9 40.7
married. (3) Early puberty: Indian
4044 12.7 14.8 9.1
2.4
15-19 years are already between 12 and 14 years. (4) Low
45-49 4.4 5.5 girls attain puberty early, of living are low, birth
322.7 332.4 289.7 standard of living: Where standards
of literacy: The 2011 census
Age-specific marital 15-19 309.0 273.6 rates are high. (5) Low level
20-24 299.8
199.0 173.2 per cent of the population was
fertility rate
190.9 showed that only 74.04
25-29 109.2 92.6 literacy is still lower, especially in the
30-34 103.4 32.7 literate. The female customs and habits: Customs
35-39 39.5 43.2
15.9 9.9 rural areas. (6) Traditionalmust marry and every man must
woman
40 44 13.7
6.1 2.7 dictate that every are considered a gift of God and their
4.9
45- 49
20.0 21.6 16.7 have a son. Children obstructed. (7) Absence of family
Crude birth rate 17.4 56.7 birth should not be planning is of recent origin.
General fertility rate
70.4
2.4 1.7 planning habit: Familyof the marital mores of the people.
Totalfertility rate
2.2
0.8 It has not yet become part
1.0 1.1
DECLINING DEATH RATE: The
declining death rate has
Gross reproduction 89.3
rate 109.2 119.1
absence of natural checks, e.g..
eneral marital fertility rate 5.1 4.4 been attributed to(1) mass control of
lotal marital fertility rate
4.9
famines and large scale epidemics, (2)
Source: (7)
592 DEMOGRAPHY AND FAMILY PLANNING
TABLE 24
Percentage of currently married women with unmet need for Modern contraceptive usage
family planning in lIndia by selected background Demand satistied by modern contraceptives
characteristics
(NFHS-4, 2015-16) Andhra
radesh
relangana 56.9
Unmet need tor
Background characteristics family planning Maharashtra 3.
62.6
For spacing For limiting Total 8 34.0
Nadu
TamilN 2.6
Age Karnataka 83.1
15-19 19.9 2.3 22.2 82.5
Haryana 9.4
20-24 15.7 6.5 22.3 J81.4
Punjab
25-29
30-34
8.4
3.1
10.3
9.4
18.7
12.5|
Madhya
Pradesh
49.6 80.9 80.9
35-39 1.0 7.3 8.3 |
Gujarat
78.1

40-44 0.3 5.5 5.8 77.9

Kerala B0.3
45-45 0.1 3.3 3.4 75.3
Residence Rajasthan
West 74.3
Urban 5.1 7.0 12.1 Bengal
Rural 72.7
5.9 7.3 13.2 Chattisgarh
Schooling3 2.5
India 47.8
No che ling .4 7.6 0 T2.0
Himachal
<5 years complete 3.8 6.3 10.1 Pradesh 5 52.1 71.7
5-7 years complete 5.0 6.6 11.7 Utarakhand 149.3
8-9 years complete 11.6
6.7 7.4 14.1 Jammu& 46.1
10-11 years complete 6.7 6.9 13.6 Kashmir 66.2
12 or more years complete 9.5 17.0 Odisha 43.4
T.5 64.0
Religion Jharkhand
Hindu
Muslim
54
7.1
7.0
9.4
12.4
16.4
Assam

Bihar .3
i.0
..0
63.8

Christian 6.9 6.0 12.9 51.4

Uttar
Sikh 2.4 4.0 6.4 Pradesh
3L 49.8
Buddhist/Neo-Buddhist 4.9 6.2 I1.1
Jain 4.0 8.0 0 10 20 30 40 50 60 70 80 90 100
12.1
Other 8.8 9.5 18.3 FIG..8
Caste/tribe Modern contraceptive use and Demand satisfied by it, India
Scheduled caste 5.4 6.7 12.1 Source:(9)
Scheduled tribe 6.2 6.8 13.0
Other backward class 6.0 7.3 13.4 coverage and quality. of family planning services,
Other 5.0 7.4 12.4 especially in the states of Uttar Pradesh, Bihar, Assam and
Don't know 7.8 11.7 19.4 Jharkhand etc.
Wealth index
Lowest .7 10.1 16.7 Contraception and adolescence (112)
Second O.8 72 13.0 Adolescence is the period between puberty and the eu
Middle 5.3 6.2 11.5 O physiological maturation, which occurs between ag
Fourth
Highest
5.4 6.4 11.8| 15-19 years. Pregnancy in adolescence constitutes aet
5.1 6.5 11.6 l per cent of all pregnancies in most developing coh
and in some developed countries such as the USA. ro
Total 5.6 7.2 12.9 year 2014, WHO puts the global adolescent birth a
49 per 1000 girls of that age, country rates range
Source (18) obe
to Z29 births per 1000 girls. This indicates a al
risk
"Demand satisfied" by modern contraceptives decrease since 1990 (113). These are often a narried
Demand satisfied' calculates the need satisfied by modern
pregnancies. Many are undesired, and occur in
adolescents who then resort to legal or illegal
t
has ais
methods out of total demand in the community (includes the
cohort using modern contraceptives and traditional methods,
periormed under unsatisíactory medical condition.
serious health and even life-threatening consearbidity
for
c
and having unmet need for contraception). India's 'demand tnese young women the ensuing mortality ana
satisfied' shows an increase from 69.1 per cent in NFHS-III to especially secondary sterility) are quite considerao
72 per cent in NFHS-IV. Fig. 8 shows the state wise 'demand Prevention of undesired pregnancies anducaliona
satisfied and modern contraceptive usage. 12 states show transmitted diseases in young people through edu
"demand satisfied' of more than 75 per cent. viour is a
programmes dealing with responsible sexua ambivalen
The National Family Health Survey-4 results show that major public health challenge. Adolescens. ar to "revea
although current use of contraception has increased, and the about family planning : to request contraceplo ometime
extent of unmet need has declined in most of the states in one's sexuality. For this reason, adolescent abortion gan
India, there is a need for considerable improvement in the choose the risk of an undesired pregnancy and o

M
 594 DEMOGRAPHY AND FAMILY PLANNING
than 5,000, type B for areas with population between
5,000-10,000, type C for population between 10,000-
,00. and type D for areas with population between
25,000-50,000. If the population is more than 50,000, then
It is to be divided into sectors of 50,000 population and
Health Posts provided. Type A, B and C Health Posts are
attached to a hospital for providing referral and supervisory
services. ype D Health Post is attached to a hospital for
sterilization, MTP and referral (32). Only type D health post
have a post of medical officer.
The 10 city family welfare bureaus are entrusted with the
responsibility of coordination, monitoring and supervision
etc. of the family welfare services provided by various
institutions in the city.
Presently there are three types of Urban Family Welfare
Centres. Type I is for population between 10,000-25,000,
type is for population between 25,000-50,000, and
type lll is for above 50,000 population (32). These are
manned by 2 para-medical staff in type I and lI centres and
by 6 persons including medical officer in type Ill centres.
The Urban family welfare centres and health posts
provide comprehensive integrated services of MCH and
family planning. The staff pattern is different for different
types of health posts and urban family welfare centres.
At the community health centre
Community health centre is established and maintained
by the state governments. Presently it is manned by four
medical specialists i.e. surgeon, physician, gynaecologist
and paediatrician, supported by 21 paramedical and other
staff. It has 30 in-door beds with one O1, X-ray, labour
room and laboratory tacilities and serves as a referral centre
for four PHCs. According to Indian Public Health Standards,
the community health centre is to be manned by 6 medical
specialists including an anaesthetist and an eye surgeon
supported by 24 paramedical and other staff with inclusion
of two nurse midwives. t provides, apart from other
emergency obstetric care, full range of family planning
services including laproscopic services and safe abortion
services. At present as of March 2018, 5,624 community
health centres are functional in the country.
At the primary health centre
Since more than 65 per cent of India's population lives in
the rural areas an adequate network of service centres has
been extended to the rural areas. A Rural Family Welfare
Centre with a medical officer and supporting staff forms an
integral part of the primary health centre. A total of 5,435
Rural Family Welfare Centres were established in the country
at all block level PHCs sanctioned upto 1.4.1980. Most of
the states have integrated these centres into their primary
health care system and after this date family planning
services are being provided through integrated facilities at
PHCs. As of March2018, 25,743 primary health centres
were functioning in the country. Each centre is supported by
Sub-centres. The total number of sub-centres functioning are
1,58,417
When fully staffed (by 3 medical officers including one
lady doctor and supporting personnel) the PHC is expected
to provide fairly comprehensive "essential health care"
including family planning care. The medical officers are
usually trained to provide MTP and sterilization services.
The programme of insertion of copper-T IUDs has
beer
intensified. It is intended that laparoscopic services whi
have become very popular will be made more
widely
available at the PHC.
The sub-centres are to prOvIde the main thrust of
programme. Each sub-centre is stalted by one male tho
ona
and
female health worker. They are responsible for providino
rudimentary health and MCH care; family plannina
motivation, supplies and serVIces in spacing
methods.
Various studies conducted have highlighted that tho
existing infrastructure is not being optimally utilized because
of its inadequacy to proviae proper Services. lo improve
matters popular commttees nave been set up at all
levels by some states to involve people in the programme
and in exercising vigilance over the work of various
functionaries.
At the village level
Two schemes are being implemented at the village level
to improve the outreach of services and increase local
participation: (a) The Village Health Guides An
innovative approach has been the creation of a band of
village Health Guides (mostly women), one for each village
or a population of 1000. They are made responsible fo
spreading knowledge and intormation to the eligible couples
and providing them with supplies of Nirodh and oral
pills. About 3.23 lakh health guides are in position.
(6) Trained dais : The national target is to provide one
trained dai per 1000 population. They conduct safe
deliveries in rural areas. They also act as family planning
counsellors and motivators, supplementing the delivery
system. (c) ASHA : 9.15 lakh ASHAs have been selected so
far and have been provided with drug kits (34A). At present
the village health guides, trained dais and ASHAs are the
lynchpins of the family planning delivery system in India.
Family planning has a significant role in mitigating the
impact of high population growth by helping women achieve
desired family size and avoid unintended and misitime
regnancies. Past few years have seen a paradigm shitt n
family planning programme. Studies show that if the curent
inmet need for family planning could be fulfilled over tne
next 5 years, 35,000 maternal deaths and 1.2 million intant
deaths can be averted. The focus of the programme is no
towards meeting the unmet need of contraception
increasing the use of modern contraceptive use, tnerr
neip in averting unintended and mistimed pregnani
achieve desired family size, and promote the healtn o
mother and child.
can De
Currently the family planning methods in India ana
broadly classified in two categories - spacing metnou
limiting permanent methods.
ich
(A) Spacing methods: These are reversible methods
can be adopted and discontinued as per an ina
choice,
(a) Oral (combined ora
contraceptives pills a
contraceptive pill (Mala N), Centchroman (Chna
(6) Condoms
effective for 10 years, IUCD 375
e
(c) Intrauterine contraceptive devices ( effective fof tor
5 years)
progra mme)
(d) Contraceptive injectable MPA (Antara
 DELIVERY SYSTEM 595
!UCD
Permanent method: These methods are irreversible in C. new method of IUCD insertion (post-partum
A
the Government.
nature nsertion) has been introduced by
Female sterilization Planning services at
(a) d. Promoting Post-partum Family or
Minilap for placement
i. district hospitals by providing training or
Counsellors and
Laparoscopic
ii. dedicated Family Planning
sterilization personnel.
(b) Male
Conventional 3. Pregnancy Testing Kits
(PTKs) was
ii. Non scalpel vasectomy (no incision no stitches) Nischay-Home based pregnancy test kits
country. he
(C)Emergency contraceptive pills launched under NRHM in 2008 across the
are being made available at sub-centres and to the
iring the year 2018-2019 the number of acceptors by hs
ASHAS to facilitate the early detection and
decision making
different meihods was as
follows (9):
for the outcomes of pregnancy.
Sterilization 35.4 lakh 4. Mission Parivar Vikas (MPV)
Total 1UCD 56.6 lakh fertility rate
A programme launched in 146 high total
Post-partum IUCD 22.9 lakh districts to accelerate the use and
awareness of tamily
Injectable MPA 9.9 lakh planning methods. States and districts fact sheet highlight
****.
the current indicators and trends in these
districts and will
Centchroman 14..1 lakh
.. act as baseline and roadmap for future work in these
Post-abortion 1UCD 80,165 districts, A five pronged strategy has been developed under
the mission parivar vikas, which comprise of (9):
Performance of social marketing programme in the sale
of contraceptives
was a. Delivering assured services;
b. Building additional capacity/human resources
Condoms 459.51 million
development for enhanced service delivery;
Oral pills 159.19 cycles
C. Ensuring commodity security;
Saheli 77.52 lakh tablets
d. Implementing new promotional schemes; and
New initiatives (114) e. Creating an enabling environment.
1. Home Delivery of Contraceptives (HDC) 5. New contraceptive launch (9)
a. A new scheme has been launched to utilize the The new contraceptive injectable MPA under "Antara
services of ASHA to deliver contraceptives at the programme and oral contraceptive pill centchroman
doorstep of beneficiaries. The scheme was launched "chhaya" have been added to the existing contraceptive
in 233 pilot districts of 17 States on 11 July 2011 basket of choice thus providing the users with new options.
and is now expanded to the entire country from The public sector provides a wide range of contraceptive
17th December 2012. services for limiting and spacing of births at various levels of
b. ASHA is charging a nominal amount irom health system as described in Table 25.
beneficiaries for her effort to deliver contraceptives at Government of India is promoting "Fixed Day Static
doorstep i.e. Rs. 1 for a pack of 3 condoms. Rs.1 for a Services" (FDS) approach in sterilization services within the
cycle of OCPs and Rs. 2 for a pack of one' tablet of
public health system with the aim ot increasing access to
ECP
sterilization services. States are being provided technical and
2 Ensuring spacing at birth (ESB) financial support for the development of human resource:
a. Under a new scheme launched by the Government of and upgradation of health facilities for the functioning o
India, services of ASHAs to be utilized for counselling FDS. In the states with high unmet need for limiting methods
newly married couples to ensure spacing of 2 years sterilization camps will continue till the time FDS
arter marriage and couples with l child to have implemented effectively. The frequency of sterilizatio
Spacing of 3 years after the birth of 1st child. The services at different health facilities at FDS is as follows (96)
Scheme is operational in 18 States (EAG, North- District hospital twice a week
castern and Gujarat and Haryana). ASHA would be
Sub-district hospital- weekly
paid following incentives under the scheme :
Rs. 500/- to ASHA for delaying first child birth by CHC/Block PHC fortnightly
2 years after marriage. 24x7 PHC/PHC -monthly
RS. 500/- to ASHA for ensuring spacing ot 3 years
Community Needs Assessment Approach (115)
after the birth of 1st child.
RS.1000/- in case the couple opts for a permanent Till recently, the achievements of family
welf
limiting method upto 2 children only. programme were assessed on the basis of the targets giv
from the centre for individual contraceptives. This led te
Inistry of Health & Family Welfare has introduced situation where the achievement of the contraceptive targ
ort term lUCD (5 years effectively), Cu IUCD 375
under the National Family Planning programme ad become the ends by themselves. Over the years=
raining of State level trainers has already been oecame apparent that there were many drawbacks in
the t
down target approach in which types and quantity
ompleted and process is underway to train servlce
providers upto the sub-centre leve.. contraceptive need to be canvassed was decided by

he international level, the International
A Planned
enthoo Federation is the world's largest
private
Parar organization supporting family planning services
volaping countries. It is an international
In dev federation of
independent Family Planning Associations
dquarters in Londo Others with long experience with
Ainclude the United Nations Fund for Population in this
fieldos(UNFPA),
the US Agency for International
Douelopment (USAD), the Population
Council,
Cndation, the Pathfinder Fund and World Bank Ford
besides
LO and UNICEF. The international agencies are assisting
in funding family planning research, services, training
and information programmes designed to
reduce the family
size.
NATIONAL FAMILY WELFARE PROGRAMME
India launched a nation-wide family planning
programme in 1952, making it the first country in the world
to do so, though records show
that birth control clinics have
been functioning in the country since 1930. The early
beginnings of the programme were modest with the
establishment of a few clinics and distribution of educational
material, training and research. During the Third Five Year
Plan (1961-66), family planning was declared as "the very
centre of planned development". The emphasis was shifted
from the purely "clinic approach" to the more vigorous
"extension education approach" for motivating the people
for acceptance of the "small family norm". The introduction
of the Lippes Loop in 1965 necessitated a major structural
reorganization of the programme, leading to the creation of
a separate Department of Family Planning in 1966 in the
Ministry of Health. During the years 1966-1969, the
programme took firmer roots. The family planning
intrastructure (e.g. primary health centres, sub-centres,
urdan family planning centres, district and State bureaus)
Was strengthened. During the Fourth Five Year Plan (1969-
74), the Government of India gave "top priority" to the
programme. The Programme was made an integral part of
MCH activities of PHCs and their sub-centres. In 1970, an
All ndia Hospital
Postpartum Programme and in 1972, the
Medical Termination of Pregnancy (MTP) Act were
ntroduced. During the Fifth Five Year Plan (1975-80) there
have been major changes. In April 1976, the country framed
s irst "National Population Policy". The disastrous forcible
enlization campaign of 1976 led to the Congress defeat in
ne 1977 election. In June 1977, the new (Janata)
overnment that came into power formulated
pulation policy, ruling out compulsion and coercion
a new
tor all
times Family Planning was
COme. The Ministry of
enamed "Family Welfare"
lthough the performance of the programme was low
png 1977-78, it was a good year in as much as the
Am me moved into new healthier directions. The 42nd
Onment of the Constitution has made "Population
Droand Family Planning" a concurrent subject, and this
acc has been made effective from January 1977, The
Ceptance of the programme is now purely on voluntary
is The launching of the Rural Health Scheme in 1977
and
Guidenvolvement of the local people (e.g., Health
es, trained
Togramn Dais, Opinion leaders) in the family welfare
accelerating at the grass level were aimed at
the pace of progress of the programme. India
NATIONAL FAMILY WELFARE PROGRAMME 599
was a signatory to the Alma Ata Declaration in 1978. The
acceptance of the primary health care approach to the
achievement of HFA/2000 AD led to the formulation of a
National Health Policy in 1982. The National Health Policy
was approved by the Parliament in 1983. It laid down the
ong-term demographic goal of NRR=1 by the year 2000 -
which implies a 2-child family norm through the
attainment of a birth rate of 21 and a death rate of per 9
thousand population, and a couple protection rate of 60 per
cent by the year 2000. The Sixth and Seventh Five Year
Plans were accordingly set to achieve these goals. The
National Health Policy also called for restructuring the
health care delivery system to achieve HFA/2000 AD, and
family planning has been accorded a central place in health
development.
The Universal Immunization Programme aimed at
reduction in mortality and morbidity among infants and
younger children due to vaccine preventable diseases was
started in the year 1985-86. The oral rehydration therapy
was also started in view of the fact that diarrhoea was a
leading cause of death among children. Various other
programmes under MCH were also implemented during the
Seventh Five Year Plan. The objective of all these
programmes were convergent and aimed at improving the
health of the mothers and young children, and to provide
them facilities for prevention and treatment of major
diseases. During 1992 these programmes were integrated
under Child Survival and Safe Motherhood (CsSM)
Programme.
The process of integration of related programmes
initiated was taken a step further during 1994 when the
International Conference on Population and Development
in Cairo recommended implementation of Unified
Reproductive and Child Health Programme (RCH). It is
obviously sensible that integrated RCH programme would
help in reducing cost of inputs to some extent because
overlapping of expenditure would no longer be necessary
and outcome will be better. Accordingly, during Ninth Five
Year Plan the RCH Programme integrates all the related
programmes of the Eighth Five Year Plan. The concept of
RCH is to provide need based, client oriented, demand
driven, high quality integrated services.
The Government of India evolved a more detailed
and comprehensive National Population Policy 2000 (see
page 574) to promote family welfare.
In the year 2005 Govt. of India launched National Rura-
Health Mission, initially for seven years (2005-2012) which
was extended for 5 years up to 2017. Then came Nationa
Urban Health Plan and merging both these plans a
National Health Mission. In the year 2013, RMNCH+
strategy was launched which was based on a continuum c
care approach and defines integrated packages of servicce
for different stages of life. In the year 2014, India Newbor
Action Plan (INAP)) came with the goal to attain single dig
neonatal mortality rate by 2030 and single digit stillbirth rat
by 2030. In the year 2017, National Health Policy wa
launched.
The investment on family welfare programme durin
successive plan-periods is tabulated below (121). It can
seen that from a modest sum of 0.65 crores during the fi
plan, the investment has reached a colossal amount
Rs. 371,600 crores during the Twelfth Plan period.
 GERIATRICS
PAEDIATRICS AND
(spontaneous onset of laboor or iollowin
OBSTETRICS, membranes(pPROMIng OM)
REVENTIVE
MEDICINE IN preterm birth rupture ot
premature rupture
of
(det
defined as
and
nductionnof
birth
618 3groups according
classified into "preterm",
to
"term and
prelabor
(2)
provider-initiated preterm
caesarean birth bef before 37 complet weeks
babies can also be word elective fetal indidications (both "ur, ent"
reasons
gestational age, using(29)
the labor or for maternal or non-medical ns.
postterm", as follows before the end of 37
weeks of gestation
"discretionary"), or other multi-factoria
Preterm: Babies born or birth is a the OCessto
gestation (less than 259
days)
completed weeks to Spontaneous preterm ot factors causing
born from 37 days) the
resulting fromquiescence
interplay contractions andus
b. lerm:
Babies weeks (259 to 293 to active The nroa.O
birth
less than 42
completed from
change completed weeks of gestation. sors to
weeks or gest.
stationalspontsOClal
age,
of gestation. 42 completed before 37 preterm birth vary by cause
Postterm : Babies born at days and over) of spontaneous but the of ous
any time thereafter
(294 environmental factors, unidentitied in upto half of case
and
gestation. of preterm labor remains preterm birth is a strong risk eniand
factor
any infant with a birth weighttwo Maternail history of interaction of genetic, igeenetic
then, likely driven by the
is
A LBW infant gestational age. It includes
2.5 kg regardless of mostenvironmental risk factors.
than
less of infants:
kinds and preterm birth also demands increa arnted
Elevated risk of health, including the conditio enata
PRETERM BABIES (9) maternal
attention to management ot NCDs and other
alive before 37 weeks diagnosis and Premahw
Preterm is defined as babies born are sub-categories of the risk ot preterm birth.
completed. There known to increase NCDs. li
of pregnancy are greater risk of developing
preterm birth, based on gestational
age babies, in turn, are at significant health
hypertension and diabetes, an other
and
extremely preterm (<28 weeks) creating intergenerational cycle of
very preterm (28 to <32
weeks) condition later in lite, prematurity and an increased risk of
preterm (32 to 37 weeks). risk. The link between public health importance when
moderate to late
early. Their intrauterine NCDs takes on an added in the rates of both
These are babies born too their weight, length and considering the reported increase the types of preterm births
growth may be normal. That is, limits for the duration of worldwide. Table 4 summarizes
development may be within normal these babies may catch and the risk factors
involved.
gestation. Given good neonatal care, will be of normal size TABLE 4
up growth and by 2 to 3 years of age
and performance. Types of preterm birth and risk
factors involved
INCIDENCE Type: Risk Factors: Examples:
in 2015 were
More than in 10 of the world's babies born
1
preterm Adolescent pregnancy,
15 million Age at pregnancy
born prematurely, making an estímated gestation) of which Sponlaneous
and pregnancy advanced maternal age,
births (defined as before 37 weeks of pretetm birth;
or short inter-pregnancy
more than 1
million died as a resulf of their prematurity. spacing
interval
of death in
Prematurity is now the second-leading cause Incrcased rates of twin and
children under 5 years, and the single most important
cause Multiple
life. For the babies who pregnancy higher orcder pregnancies
of death in the critical first month of with assisted reproduction
survive, many face a lifetime of significant disability.
Infection Urinary tract infections,
Preterm births is a global problem. More 1han 60 per cent malaria, HIV, sypihilis,
of preterm births occur in Africa and South Asia. In the lower bacterial vaginosis.
income countries, on average, 12 jper cent babies are born
Underlying Diabetes, hypertension,
too early compared 1o 9 per cent in higher-income countries.
Within countries, poorer families are at higher risk. The
maternal chronic anaemia, asthma, thyroid
10 countries with the greatest number of preterm births in
nedical conditions disease
2015are: (1) India 3519100; (2) China 1172300:(3) Nigeria Nutritional Undernutrition, obesity,
micronutrient deficiencies
773600; (4) Pakistan 748100; (5) Indonesia 675700; (6) USA
517400; (7) Bangladesh 424100; (8) Philippines 348900; Lifestyle Smoking, excess alcohol
(9) DPR of the Congo 341400; and (10) Brazil 279300 (31). work related consumption, recreational
drug use, excess physical
The 10 countries with the highest rates of preterm birth work/activity
per 100 ive births is; (1) Malawi 18.1; (2) Comoros 16.7:
(3) Congo 16.7; (4) Zimbabwe 16.6: (5) Equatorial Guinea Maternal Depression, violence
16.5; (6) Mozambique 16.4; (7) Gabon 16.3;: (8) Pakistan psychological against women
health
15.8: (9) Indonesia 15.5; and (10) Mauritania 15.4 (31).
Genetic and other Genetic risk, e.g., family
There is a dramatic difference in survival of premature
babies depending on where they are born. More than 90 per history, Cervical
incompetence
cent of extremely preterm babies (less than 28 weeks) born Provider- Medical induction There is an overlap for
in low-income countries die within the first few days of life; initiated or caesarean birth indicated provider-initia
yet less than 10 per cent of extremely preterm babies die in preterm birth:
high income countries. for obstetric preterm birth with the ris
indication, Foetal factors for spontaneous
indication
Causes of preterm births (9) preterm birth.
Other-Not medically
Preterm birth is a syndrome with a variety of causes
which indicated
can be classified into two broad subtypes: (1)
spontaneous Source (9)
 OW BIRFH WEIGHT 619
ALL-FOR-DATE (SFD) BABIES babies may experience
Some of the problems premature
as small for gestational age babies. These include (34):
Also nown stay warm due to
at term or preterm. They weigh less than the Temperature instability inability to
may be born
percentile gestational age. These babies are low body fat
10th
10tn
the result of retarded intrauterine foetal growth. Respiratory problems;
disease/respiratory distress
Computation The percentage of LBW babiesis hyaline membrane the airsacs cannot
computed as syndrome a condition in which in the lung
Live-born babies with birth weight less than 2.5 Kg stay open due to lack of surfactant
x 100 disease/bronchopulmonary dysplasia
chronic lung by injury to the
Total number of live births long-term respiratory problems caused
The factors assoCiated
with intrauterine growth lung tissue
otardation are multiple and interrelated to mother, the - air leaking out of the normal lung
spaces into other
lacenta or to the toetus. The maternal factors include tissues
malnutrition, severe anaemia, heavy physical work during incomplete lung development
half of
Dregnancy, hypertension, malaria, toxaemia, smoking, low apnea (stopping breathing) occurs in about
oconomic status, short maternal stature, very young age, babies born at or before 30 weeks
hioh parity and close birth spacing, low education status etc.
132). The placental causes include placental insufficiency Cardiovascular
-patent ductus arteriosus (PDA) a heart condition
-

and placental abnormalities. ihe foetal causes include foetal to divert away from the lungs
abnormalities, intrauterine infections, chromosomal that causes blood
abnormality and multiple gestation. too low or too high blood pressure
-
SFD babies have a high risk of dying not only during the
low heart rate often occurs with apnea
neonatal period but during their infancy, thus significantly .Blood and metabolic;
raising the rate of intant and perinatal mortality and anaemia- may require blood transfusion
contribute greatly to immediate and long term health jaundice due to immaturity of liver and
problems. Most of them become victims of protein-energy gastrointestinal function
malnutrition and infections. - too low or too high levels of minerals and other
In the developing countries, adverse prenatal and post- substances in the blood such as calcium and glucose
natal development of the child is associated with (sugar)
3 interrelated conditions malnutrition, infection and Gastrointestinal;
unregulated fertility which are often due to poor socio are unable to coordinate
difficulty feeding many
-
economic and environmental conditions.
suck and swallow before 35 weeks gestation
IMPORTANCE poor digestion
LBW is one of the most serious challenges in maternal and
necrotizing enterocolitis (NEC) a serious disease of
-

child health in both developed and developing countries. Its

the intestine common in premature babies
public health significance may be ascribed to numerous Neurologic;
factors its high incidence; its association with mental intraventricular haemorrhage bleeding in the brain
-

retardation and a high risk of perinatal and infant mortality periventricular leukomalacia softening of tissues of
- -

and morbidity (half of all perinatal and one-third of all infant
deaths are due to LBWw); human wastage and suffering; the
very high cost of special care and intensive care units and its
association with socio-economic underdevelopment (33).
LBW is the single most important factor determining the
Survivalchances of the child. Many of them die during their
irst year. The infant mortality rate is about 20 times greater
oral LBW babies than for other babies. The lower the birth
weight, the lower is the survival chance. Many of them
come victims of protein-energy malnutrition and
ection. LBW is thus an important guide to the level of care
Heeded by individual babies. LBW also reflects inadequate
rition and ill-health of the mother. There is a strong and
iticant positive correlation between maternal nutritional
aus and the length of pregnancy and birth weight. A high
ercentage of LBW therefore points to deficient health status
fregnant women, inadequate prenatal care and the need
1Or
improved care of
the newborn.
Premature babies are born before their bodies and
heahstems have completely matured, they may need
Veru aning, eating, fighting infection and staying warm.
premature abies who are born before 28 weeks, are
ecially vulnerabl Many of their organs may not be
Teady
for life utside
immature the mother's uterus and may be too
to function well.
the brain around the ventricles (the spaces in the brain
containing cerebrospinal fluid).
-poor muscle tone
seizures may be due to bleeding in the brain
retinopathy of prematurity abnormal growth of the
blood vessels in a baby's eye
Infections premature infants are more susceptible to
infection and may require antibiotics
PREVENTION
Experts opine that the rates of LBW babies could be
reduced to not more than 10 per cent in all parts of the
world (35). It is clear from the multiplicity of causes
there is no universal solution. Interventions have to
that
be
cause-specific. ain attention has been given in recent
years to ways and means of preventing LBW through good
prenatal care and intervention programmes, rather
"treatment" of LBW babies born later. than
DIRECT INTERVENTION MEASURES
The incidence of LBW can be reduced if pregnant
women
"at risk" are identified and steps are taken to reduce
For this approach the women need to be identified the risk.
pregnancy. To achieve this goal, the mothers early in
health card -

The objectives ot tne scheme are: (1) Improve access too
and quality of child protection
services; (2) Raise public
areness about child rights; (3) Clearly
articulated
responsibilities and accountability for child protection;
4) Establish structures at all government levels for
delivery ot statutory and support services to
children in
difficult circumstances, and
) Setting-up of an
evidence based monitoring and evaluation system.
Theservices provided under ICPS are as follows
(1) Emergency outreach service through 'Child
line',
dedicated number is 1098. It is a 24-hour toll free
telephone service available to all children in distress.
(2) Open shelters for children in need, in urban
and
semi-urban areas.
(3) Family based non-instifutional care through
sponsorship, foster-care, adoption, cradle baby
centres and after-care.
(4) Institutional services through shelter homes, children
homes, observation homes, special homes, and
specialized services for children with special needs.
(5) Web-enabled child protection management system
including website for missing children.
(6) General grant-in-aid for need based interventions.
9. National Policy for Children 2013 (NPC) (67)
The National Policy for Children 2013 is a long term
Sustainable, multi-sectoral, and integrated approach
for the development and protection of children i.e.
0-18 years age group. Survival, health, nutrition,
development, education, protection and participation
are the key priorities of the policy. It reiterates the
State's commitment to ensure uitable access to
essential, preventive, promotive, curative and
rehabilitative health care for all children. Towards this
goal, NPC envisages that state shall take measures to:
Improve maternal health care (pre-natal, natal,
post-natal);
Provide universal access to services for intormed
choices related to births and spacing;
Address key causes of child mortality through
appropriate interventions including access to sate
drinking water and sanitation
To improve new born and child care practices
To protect children from water borne, blood borne,
vector borne, communicable and other childhood
aiseases by providing universal and affordable
ess to appropriate services;
Prevent disabilities, physical and mental through
timely measures to take pre-natal, natal, perl-natal
and post-natal care of mother and child;
Cnsure availability of services, support and
provisions for nutritive attainment in a life cycle
approach with focus on infant and young child
eeding (IYCF) practices and on the health and
nutrition needs of adolescent girls and other
Vulnerable groups
Prevent HIV infections at birth and ensure proper
treatment to infected children; and
rovide the adolescents access to information
use,
ill effects of alcohol and substance
rding
and support for the choice of healthy life style.
tate commits to allocate the required financial,
ofa and human resources for the implementation
Ministry of Women& Child
PC 2013.is Thenodal ministry for implementation
Opment the
of NPC.
1
NATIONAL POLICY FOR CHILDREN 637
10, Protection of Children from Sexual Offences (POCSO)
Act, 2012
In order to effectively address the heinous crime ot
sexual abuse and sexual exploitation of children
tnrough less ambiguous and more stringent legal
provisions, the Ministry of Women and Child
Development introduced the Protection of Children
from Sexual Offences (POCSO) Act, 2012.
The Act defines a child as any person below 18 years of
age and regards the best interest and well-being of a
child as being of paramount importance at every stage
to ensure a healthy physical, emotional, intellectual
ana social development of the child. It detines ditterent
forms of sexual abuse, including penetrative and non
penetrative assault, as well as sexual harassment and
pornography, and deems a sexual assault to bee
aggravated" under certain circumstances, such as
when abused child is mentally ill or when the abuse is
committed by a person in aposition of trust or
authority vis-a-vis the child, like a family member,
police officer, teacher or doctor. People who traffic
children for sexual purpose are also punishable under
the provisions relating to abetment in the said Act (68).
An ordinance providing the death penalty for rapist of
girls below 12 years of age "The Criminal Law
Amendment Ordinance, 2018 was promulgated. The
salient features of the Ordinance are:
a. Minimum punishment for rape made 10 years;
b. Minimum punishment of 20 years to a person
commiting rape on a girl aged below 16 years;
C. Minimum punishment of 20 years rigorous
imprisonment and maximum death penalty / life
imprisonment for committing rape on a girl aged
below 1Z years,
d. Police otticer committing rape anywhere shall be
awarded rigorous imprisonment of minimum
10 years
e. Investigation of rape cases to be completed within
2 months;
Appeals in rape cases to be disposed within 6
months; and
No anticipatory bail can be granted to a person
accused of rape of girl of age less than 16 years.
The POCSO Act 2012 was further ammended in the year
2019 with insertion of the following clause:
Under the Act, a person is guilty of using a child for
pornographic purposes if he uses a child in any form of media
forthe purpose of sexual gratitication. The Act also penalises
persons who use children for pornographic purposes resulting
in sexual assault. The Bill detines child pornography as any
visual depiction ot sexually explicit conduct involving a child
including photograph, vide0, digital or computer generated
image indistinguishable irom an actual child. The punishment
is minimum 5 years in Ja. Ihe Act penalises storage
of
pornographic material 1or commercial purposes with a
punishment of upto three years, or a tine or both (68A).
The POCSO ammendment Bill 2020 proposes that
child
derween 5 and 18 years of age should he
e
enders
under the ambit of the POCSO Act 2012 and be given the
same punishment as is given to adults (68B).
The growing vulnerability of children in urban settlements,
including those caught in the shitting frame migratory
of and
transient labour are also now in the MWCD portfolio. Their
dI5tress and the aicult circumstances of their childhoode
merit special measures of development
and protection.
, 1
 640 HEVENTIVE MEDUCINE IN MSTTRcs, ADIATRICS ANV GERIATRIE S

TABLE 11
MCII goals and cent lecl of aclhievement (media)
EET A Goals and target period
Indicator Current National Health Sustainable n
Three Year Actlon Agenda
level
of Nitl Ayog (2018-19-20) Policy 2017 D eloprment
ls (2030men
0als
A Family Planning Indicators
Crude birth rate 21
20.0 (2018)
by 2025
Total fertility rate
Couple protection
2.2 (2018) 2. 1 2.1
Meet all needs
rate ( 67.0 (2015-19)
B. Mortality indicators per 1000
lnfant mortality 32 (2018) 30 28 by 2019
Neonatal mortality 23 (2018) 16 by 2025
100 by 2020
12
Maternal mortality per 100,000 113 (2016-18) 120 70
Under-5 mortality 36 (2018) 38 23 by 2025 S25
C. Services ( coverage)
Infants immunized (2018) 90 by 2025
- Measles
80
- DPT 89
-Polio 89
- BCG 92
-
HepB, 89
Hib, 89
- Rotavirus 35
- PCV 6
Pregnant women TT 87.0
Antenatal care coverage % (2013-2018) 100
at least once 79.0
at least four times 51.0 90
Institutional deliveries 79.0 (2013-2018) 80
Deliveries by trained personnel 81.0 (2013-2018) gT S 100 i
D. Prevalence of low-birth-weight babies 28 (2011-2016)

Source: (5, 69)

restructuring the health services, based on primary health Municipal Corporations and voluntary organizations, TH
care approach with short and long-term goals. services of obstetricians are available at district hospita
The infrastructure in rural areas is based on the complex of which are the apical hospitals tor MCH care at the distr
community health centres, primary health centres and their level. For specialized care of children, paediatric units ha-
subcentres. They provide preventive and promotive health been established in several district hospitals.
care services. Since deliveries by trained health personnels Table 12 shows the evolution of maternal and c
are crucial in reducing maternal and infant mortality in rural health programmes in India.
areas, the government of India undertook a scheme to train
local dais to conduct safe deliveries. These dais are now TABLE 12
available in most villages. Mention must be made of ICDS Evolution of maternal and child health programmes in ir-
(Integrated Child Development Services) projects which are
functioning all over the country providing a package of basic Year 1is Milestones
health services (eg. supplementary nutrition, immunization,
1952 Family Planning programme adopted by Governme
health check-up, referral, nutrition and health education, and India (GOI)
non-formal education services) to mother and children. 1961 Department of Family Planning created in Ministry
Maternal health care was a part of family welfare Health
programme from its inception. Interventions were introduced 1971 Medical Termination of Pregnancy Act (MTP Act),?
on vertical schemes, but family planning remained a 1977 Renaming of Fainily Planning to Family Welfare
separate intervention. In 1992, the Child Survival and Safe 1978 Expanded Programme on Immunization (EPI)
Motherhood Programme integrated all the schemes for better 1985 Universal Immunization Programme (UIP)+
compliance. More recently, Reproductive and Child Health s National Oral Rehydration Therapy (ORT) Progra
Programme was launched in 1997, which integrated family 1992 Child Survival and Safe Motherhood Programme
planning, Child Survival and Safe Motherhood Programme, (CSSM)
Preventive management of STD/RTI, AlIDS, and a client 1996 Target-free approach
approach to health care. This programme has entered into 1997 Reproductive and Child Health Programme-1 (RC
phase II, with reorientation to make it consistant with the 2005 Reproductive and Child Health Programme-2 (R
requirement of the National Rural Health Mission. 2005 National Rural Health Mission
2013 RMNCH+A Strategy
In urban areas, the general trend is towards institutional
2013 National Health Mission
delivery. In larger cities, almost 90 per cent of deliveries
take place in maternity hospitals and maternity homes.
2014 India Newborn Action Plan (INAP)
Some of the institutions are under the auspices of the Source: (70)
 INDICATORS OF MCH CARE
INDICATORS OF MCH CARE 641
six-week (42 day) postpartum period, and the increased
Maternal and child health status is assessed availability of modern life-sustaining procedures and
asurements of mortality morbidity and,
through
growth and Technologies enables more women to survIve advee
development. In many countrie mortality rates are still outcomes of pregnancy and delivery, and also delays some
source of intormation. Morbidity data are scarce the deaths beyond that postpartum period. Specific codes for
only
standardized. In recent years, attention has and
0or systematizing been paid ate maternal deaths", are included in the ICD-10 (096 and
o the collection, interpretation 097) to capture these delayed maternal deaths, which may
0ination of data on growth and development. and not be categorized as maternal deaths in civil registration
The
rommon sed mortality indicators of MCH care are and vital statistics systems despite being caused by
pregnancy-related events.
1. Maternal mortality ratio
2. Mortality in infancy and childhood
Maternal deaths and late maternal deaths are combined
in the 11th revision of the ICD under the new grouping of
a. Perinatal mortality rate
"comprehensive maternal deaths".
b. Neonatal mortality rate
Post-neonatal mortality rate Pregnancy-related death (also known as death occurring
C.
during pregnancy, childbirth and puerperium): is defined as
d. Infant mortality rate
e. 1-4 year mortality rate
he death of a woman while pregnant or within 42 days of
termination of pregnancy, irrespective of the cause of death
f. Under-5 mortality rate (obstetric and non-obstetric)"; this definition includes
g. Child survival rate. unintentional/accidental and incidental causes. his
definition allows measurement of deaths that occur during
MATERNAL MORTALITY RATIO pregnancy, childbirth and puerperium while acknowledging
that such measurements do not strictly conform to the
According to WHO, a maternal death is defined as "the standard "maternal death" concept in settings where
death of a woman while pregnant or within 42 days of accurate information about causes of death based on
termination of pregnancy, irrespective of the duration and site medical certification is unavailable (1).
of pregnancy, from any cause related to or aggravated by the
The number of maternal deaths in a population (during a
pregnancy or its management but not from unintentional or specified time period, usually one calendar year) reflects two
incidental causes" (1). factors: (i) the risk of mortality associated with a single
This definition allows identification of a maternal death, pregnancy or a single birth (whether live birth or stillbirth):
based on the cause of the death being identified as either a and (ii) the fertility level (i.e. the number of pregnancies or
direct or indirect maternal cause. It is calculated as births that are experienced by women of reproductive age,
i.e. age 15-49 years).
Total no. of female deaths due to Maternal mortality ratio (MMR): is defined as the
complications of pregnancy, childbirth or
within 42 days of delivery from "puerperal number of maternal deaths during a given time period per
100,000 live births during the same time period; thus, it
causes" in an area during a
Total no. of live
given
births in the same
x 1000 (or 100,000) quantifies the risk of maternal death relative to the number
of live births, and essentially captures the first factor
area and year
mentioned above (1).
Direct obstetric deaths (or direct maternal those
deaths) Maternal mortality rate (MMRate) is defined and
pregnant state
resulting from obstetric complications of the calculated as the number of maternal deaths divided by
pregnancy, labour and puerperium), from interventions person-years lived by women of reproductive age in a
omissions, incorrect treatment, or from a chain of population. The MMRate captures both the risk of maternal
events resulting from any of the above. Deaths due too death per pregnancy or per birth (whether live birth or
obstetric haemorrhage or hypertensive disorders in stillbirth), and the level of fertility in the population (i.e.
PEgnancy, for example, or those due to complications of both factors mentioned above) (1).
Estnesta or caesarean section are classitied as direct
maternal deaths (1).
Adult lifetime risk of maternal death for women in the
population, is defined as the probability that a 15 year-old
ndirect obstetric deaths (or indirect maternal deaths) girl (in the year of the estimate) will eventually die fromh a
that
resulting from previous existing disease or diseasedirect maternal cause. This indicator takes into account competing
ieveloped during egnancy and which was not due to causes of death (1).
obstetric causes, but which was aggravated by physiological The proportion of maternal deaths of women of
s Of pregnancy. For example, deaths due to aggravation

Pregnancy) of an existing cardiac or renal disease

are
reproductive age (PM): The number of maternal deaths in a
given time period divided by the total deaths, among
Onsidered indirect maternal deaths. women aged 15-49 years.
hoTh maternal mortality rate, the direct obstetric rate and The 43rd World Assembly in 1990 adopted the
quality Of recommendation that countries consider the inclusion on
mateCt obstetric rate are fine measures of the
maternity
services. death certificates of questions regarding current pregnancy
Late from and pregnancy within one year preceding death in order to
dirertaternal death: "the death of a woman days
It is
improve the quality of maternal mortality data and provide
than 42
obstetric causes, after more
but lese
rect
less than one yea
after termination of pregnancy"both
(1). alternative methods of collecting data on deaths during
pregnancy or related to it, as well as to encourage the
al deaths, late maternal deaths also include
direct and recording of deaths from obstetric causes occurring more
ofpre indirect ternal/obstetric deaths. Complications than 42 days following terminatiorn of pregnancy.
ancy or childbirth can lead to death beyond the
 642 NEVENTVE MEDICINE IN ORSTETRICS, PAEDIATRICS AND GERIATRICS

Approaches for measuring maternal mortality (1) Between 2000 and 2017, the
sub.roet.
In theabsence of complete and accurate civil registration achieved the greate percentage reductionion of
Systems, MMR estimates 384 to 157 (59 per cent). Central Asia (59MMR, i
Souh
are based upon a variety of methods
(1) Civil registration systems Asia (50 per cent), Europe (53 per cent
This approach involves (54 per cent) halved their MMR during).
Cent
Northern
routine registration of births and deaths. Ideally, materna that period ae
mortality statistics should be obtained A woman is most vulnerable
through civil at the post.
st-parlum
registration data. About 50-70 per cent aternal deaths
(2) Household survey: postpartum period of which pe
Where civil per cent OcOr
not available, household survey providesregistration data are first 24 hours atter delivery deaths
and more than tu occuri
in
an alternative. the first week.
(3) Sisterhood methods Sisterhood methods obtain Between 11-17 per of
information by interviewing a representative sample occur during child birth itself (71). cent ternaldez
respondents about the survival of all their adult sisters (to of Maternal mortality ratios
strongly
determine the number of ever marrried sisters, how many effectiveness of health systems, which reflect the tho
are alive, how many are dead, and how many in ov
developing countries sutter from
died during
pregnancy, delivery, or within six weeks of pregnancy. technical and logistical capacity, weak
inadeu
a- a-
lov

(4) Reproductive-age mortality studies (RAMOS) : invesment and a lack of skilled health personnel financ
This
approach involves identifying and investigating the causes key interventions for example, increasing Scal
the n
-

of all deaths of women of reproductive age in
a detined
area/population by using multiple sources of data.
(5) Verbal autopsy This approach is used
:
to assign cause
of death through interview with family or community
members, where medical certification of cause of death is
not available. Records of births and deaths are collected
periodically among small populations, under demographic
surveillance systems maintained by the research institutions
in developing countries.
(6) Census: A national census, with the addition of a limited
number of questions, could produce estimates of maternal
mortality; this approach eliminates sampling errors and hence
allows a more detailed breakdown of the results, including time
trends, geographic subdivisions and social strata.
births attended by skilled health personnel,. providino
a
emergency obstetric care when necessary ngaes
and providina
natal care for mothers and babies-could sharnlr r
reduceba
maternal and neonatal deaths. Enhancing
family planning, adequate nutrition, women's aCre
improved water-
sanitation facilities and affordable basic health
care proteri
from abuse, violene, discrimination, empowerment
of
greater involvement of men in maternal and child wome
care. we
lower mortality rates further still. These are not imposit
impractical actions, but proven, cost-eftective provision
women of reproductive age have a right to expect.
The low status of women in the society coupled with t=
low literacy levels prevent the women from taking antena
care even if services are available. Most deliveries take pam

Incidence at home without the services of the trained miduile=

WORLD SCENARIO
The methodology employed by the Maternal Mortality
Estimation Inter-Agency Group to estimate 1990-2015
maternal mortality ratio followed an improved approach
referred to as Bayesian maternal mortality estimation model
personnel. There is an inverse relationship between liatir
risk of maternal death and the availability of the traits
health worker during pregnancy and at the time of delive
It is a tragic situation as these deaths are not caused
disease but occurred during or after a natural proces. i
one of the leading cause of death for women of reprodu
arm

or B Mat model. These results supersede all previously age in many parts of the world. Most maternal deaths
published estimates for the years within that time period and pregnancy complications can be prevented if prey
differences with previously published estimates should not Women have access to good-quality antenatal, natal d
be interpreted as representing time trends (1). postnatal care, and if certain harmful birth practices
An estimated 295,000 maternal deaths occurred globally avoided. Estimates of antenatal care coverage. d
in 2017, yeilding an overall MMR of 211 (199-243) conducted by skilled personnel, lifetime risk of m
maternal deaths per 100,000 live births. The global adult death and maternal mortality ratio in some developing
life-time risk of maternal mortality (i.e. the probability that a developed countries are shown in Table 13.
urvival
15 years old woman will die eventually from a maternal Maternal health, however, goes beyond the
cause) is approximately 1 in 190 for the year 2017. For the pregnant women and mothers. For every woiatina
purpose of categorization, MMR is considered to be high if it rom causes related to pregnancy or childbirth, itin elatedi
is 300-499, very high if it is 500-999, and extremely high if that there are 20 others who suffer pregnan number
it is 2 1000 maternal deaths per 100,000 live births (1). or experience other severe consequences. aly annua
MMR in the world's least developed countries is high, striking: An estimated 10 million women outcome
verse
estimated at 415 maternal deaths per 100,000 live births Survive their pregnancies experience such advet
which is more than 40 times higher than MMR in Europe
(10), and almost 60 times higher than in Australia and New
Causes trimester
third
Zealand (7). The lifetime risk of maternal death in least Maternal deaths mostly occur from the deathsdue
the first week after birth (with the exception of ortality
risk
developed countries is 1 in 56, Sub Saharan Africa is the
only Region with very high MMR for 2017, estimated at 542 complications of abortion). Studies show thati firsttwo etm
with life. time risk of maternal death at 1 in 37. Three the to obs
for mothers are particularly elevated within haemoritha4
after birth. Most maternal deaths are relate
countries namely, South Sudan (1150), Chad (1140) and postpartum labo
Sierra Leone (1120) fall under extremely high MMR in 2017. complications including bstructedcauses
Nigeria (67000) and India (35000) had the highest estimated infections, eclampsia and olonged or direct heae
se
number of maternal deaths accounting for approximately and complications of abortion. Most ot skilled
35 per cent of estimated global maternal deaths (1). maternal mortality can be readily addres>
 INDICATORS OF MCH CARE 643
TABLE 13
Maternal mortality ratio. deliveries conducted by skilled personnel, e
and litetime risk ot maternal deaths in
antenatal care ove
some developing and developed couu
Antenatal care Deliveries conducted by Lifetime risk Maternal mortality
Counry coverage (%) (2013-2018) skilled personnel (%) maternal death ratio (per 100,000
At least once Ai least four times (one in) (2017) live births) (2017)
(2013-2018)
9
81 290 113 (2016-18)
Bangiadassh 64 31 173
42 250
98 85 250 183
Bhutan 75
98 77 94 240 177
ndonesa
yanmar 81 59 60 190 195
Nepal 84 69 58 186 220
Thaiand 98 91 99 1,900 37
99 93 1,300 36
Si Lanka 100
86 51 69 140 188
Pakistan
100 81 100 2,100 29
China
Japan 100 100 100 16,700
Singapare 100 100 100 9,900
UK 99 8,400
USA 97 99 3,000 19
World 86 65 81 190 211

Source:(72)

personnel are on hand and key drugs, equipment and treatment with relatively simple anticonvulsant drugs in
are available.
referral facilities cases of eclampsia.
About 80 per cent of maternal deaths are due to direct Of the estimated 210 million pregnancies that occur
causes i.e. obstetric complications of pregnancy, labour and every year, about 42 million end in induced abortion, of
puerperium to interventions or incorrect treatment. As shown which only approximately 60 per cent are carried out under
in Fig. 10 the single most common cause-accounting for a safe conditions. More than 20 million induced abortions
quarter of all maternal deaths is obstetric haemorrhage, each year are performed by people lacking the necessary
generally occurring postpartum which can lead to death very skills or in an environment lacking the minimal medical
rapidly in the absence of prompt life-saving care. standards, or both.
Puerperal infections, often the consequence of poor Around 8% of maternal deaths occur as a result of
hygiene during delivery, or untreated reproductive tract prolonged or obstructed labour. Other direct causes inclu
infections account for about 15% of maternal mortality. ectopic pregnancies, embolism and deaths related to
Such infections can be easily prevented.Hypertensive interventions. Around 20 per cent of maternal deaths are due
disorders of pregnancy, particularly eclampsia (convulsions), to indirect causes, that is, the result of pre-existing diseases or
Tesult in about 13% of all maternal deaths. They can be disease that developed during pregnancy, which are not due
prevented through careful monitoring during pregnancy and to direct obstetric cause but are aggravated by the
physiological effect of pregnancy. One of the most significant
Severe bleeding is anaemia, which can cause death. Maternal anaemia affects
about half of all pregnant women. Pregnant adolescents are
more prone to anaemia than older women, and they often
Indirect causes 25% receive less care. Infectious diseases such as malaria, and
intestinal parasites can exacerbate anaemia, as can poor
20% quality diet all of which heighten vulnerability to maternal
15% Infection death. Severe anaemia contributes to the risk of death in
cases of haemorrhage. Other important causes of indirect
8%
12%
death are hepatitis, cardiovascular diseases, diseases of the
13%
endocrine and metabolic system and infections such as
8% tuberculosis, malaria and increasingly HIV/AIDS (73). Each
Other direct
causes
Eclampsia year, approximately 50 million women living in malaria-
endemic countries throughout the world become pregnant.
Around 10,000 of these women die as a result of malaria (74).
Unsafe abortion Obstructed labour Social correlates
irect causes including for example: ana
naemia, A number of social factors influence maternal mortality.
malaria, heart diseases
The important ones are (a) Women's age: The optimal
er ditect causes including, for example:
ancy, embolism, anaesthesia-relate
ectopic
child-bearing years are between the ages of 20 and 30 years.
The further away from this age range, the greater the risks
FIG. 10 of a woman dying from pregnancy and childbirth.
Causes of maternal deaths worldwide
644 PREVENTIVE MEDICINE: IN SIETRICS. ADIAIRICS ANE) Ci RIATERICS
(6) Birth interval
an
Short birth intervals are assoclaled wilh
: Ellminale all harmful practices and all discriminae
increased risk of maternal mortality. (c) Parlty: High
parity contributes to high maternal mortality.
Not only are thesc
are also other factors three variables interrelated, but there
which are involved, e.g.. economic
Circumstances, cultural practices and beliefs, nutrilional
status, environmental conditions and violence against
women. The social factors often precede the medical causes5
and make pregnancy and child-birth a risky
venture.
Global Strategy Children's aud
for Women's,
Adolescent's Health 2016-2030
The Global Strategy for Women's, Children's and
Adolescent's Health, 2016-2030 was launched in the year
2015 with a vision to have by the year 2030, a "world in
which every woman, child and adolescent in every setting
realize their rights to physical and mental health and well-
being, has social and economic
opportunities, and is able to
participate fully in shaping prosperous and sustainable
SOciety (75). The strategy is a road map for the
post-z015
agenda as described by the Sustainable Development Goals
and seeks to end all preventable
deaths of women, children
and adolescents and create an environment in which these
groups not only survive, but thrive, and see
their
environments, health and wellbeing transformed. The global
strategy goals of SURVIVE, THRIVE and TRANSFORM and
the targets to be achieved by 2030 are as follows (75):
SURVIVE
End preventable deaths
Reduce global maternal mortality to less than 70 per
100,000 live births
Reduce newborn mortality to at least as low as 12
per 1000 live births in every country
Reduce under-5 mortality to at least as low as 25 per
1000 live births in every country 1
End epidemics of HIV, tuberculosis, malaria, neglected
tropical diseases and other communicable diseases
Reduce by one third premature mortality from non-
communicable diseases and promote mental health
and well-being
THRIVE
Ensure health and well-being
End all forms of malnutrition, and address the
nutritional needs of adolescent girls, pregnant and
lactating women and children
Ensure universal access to sexual and reproductive
health-care services (including for family planning)
and rights
Ensure that all girls and boys have access to good
quality early childhood development
Substantially reduce pollution-related deaths and
illnesses
Achieve universal health coverage including
financial risk protection and access to quality
essential services, medicines and vaccines t
TRANSFORM
Expand enabling environment
Eradicate extreme povertys t rt.
Ensure that all girls and boys complete free,
equitable and good quality primary and secondary
education
ation
and violence against women and girls
Achieve universal and equitable access to safea
affordable drinking water, and to adeaquate
sanitation and hygiene
Enhance scientific research, upgrade technolon
capabilities and encourage innovation
- Provide legal identity for all, including birth
registration
Enhance the global partnership for sustainable
development,
INDIA
Despite significant improvements in maternal health over
the last decade or so, which is evident in the reductions in
maternal mortality in the country, an estimated 44.000
mothers continue to die every year due to causes related to
pregnancy, childbirth and the postpartum period. The
major medical causes ot these deaths are haemorrhage
sepsis, abortion, hypertensive disorders, obstructed labor
and other causes including anaemia. A host of socio
economic-cultural determinants like illiteracy, low socio-
economic status, early age of marriage, low level of women's
empowerment, traditional preference for home deliveries
and other factors contribute to the delays leading to these
deaths.
From year 2000 onwards, SRS (Central registration
system) included a new method called the "RHIME" or
Representative, Re-sampled, Routine Household Interview
of Mortality with Medical Evaluation. This is an enhanced
form of "verbal autopsy" which is the key feature of a
prospective study of 1 million deaths within the SRS. RHIME
,
include random re-sampling of field-work by an
independent team for maintaining quality of data. For
comparability with WHO estimates for India and for other
countries, the WHO's Global Burden of Disease"
categorizaton of maternal deaths have been used, which
includes various categories with their ICD-10 codes such as
haemorrhage, sepsis, hypertensive disorder, obstructed
labour, abortion, and other conditions.
The SRS report has been grouped into three categories
(a) EAG states of Bihar and Jharkhand, Madhya Pradesh
and Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh and
Uttaranchal and Assam. These states have high mortalit
indicators; (b) This category includes southern states o
Andhra Pradesh, Karnataka, Kerala and Tamil Nadu. Thes
states have comparatively better health indicators; (c) Th
remaining states have been classified as others (76).
Table 14 shows live births, maternal deaths, materr
mortality ratio in India by states during 2016-2018, spec
survey of deaths using RHIME. During this period
life time risk of maternal death of women in the age grc
15-49 has been reported to be 0.3 per cent. This
substantially higher for women in the category EAG st
and Assam (0.5 per cent) as compared to women in
category southern (0.1 per cent) or in the "other" st
(0.2 per cent).
India is among those countries which have a
maternal mortality ratio. According to the estimates the
has reduced from 167 per lakh live births in 2011-
113 per lakh live births in 2016-18. States of K
Maharashtra, Andhra Pradesh, Gujarat and Tamil Nadt
already achieved the goal of a MMR of 100 per lak
births. In EAG and Assam category of states, MMR is
161 per lakh live births, with Assam on top (215
 CARE
645
INDICATORS OF MCH

to the
TABLE 14 CauseS mortality according
maternal
Maternal mortality ratio
(MMR)
e major causes of haemo ont)
obstructed
rate and litetime risk; India 2001-2003 SRS survey are cen ot and otner
mortality
nalAssam,outh and other states, 2016-2018 sepsis (11 per cent), hype n(8(8 per cent) only
abortion per cent tactorin
per cent), Anaemia (19 aggravating
EAGand aoour(6
Conditions (34 per cent).
MMR 95% CI Maternal Lifetime
cause of deathtoxaemia.
an
but also Illegal abortions are also
mortality risk
eading shourd
tndiaand
states rate aemorrhage, sepsis and maternal death. That this wider
of need for
major leading causes the
facilities points to facilities. 1nau
113 (103-123) 7.3 0.5%
Oe or thedespite MTP about these contraceptives
Total
India 215 (133-297) 14.0 0.5% ninue
dissemination of
information
large unmet need forincreased risk O
(104-194) 15.1 0.5% point to a faces
the woman of causes of materna
Assam
149 aOordons also pregnancy
(20-123) 5.6 0.2%
71
ds With each distribution in Fig
The percentage2001-2003 are as shown
Bihar (126-221) 15.9 0.6%
Jharkhand 173
Pradesh
159 (69-249) 12.1 0.4% eath. during the year
Madhya
7 0.3% deaths
Chhatisgarh 150 (96-205)
Odisha 164 (112-215) 14.5 0.5% Other conditions
Rajasthan 197 (152-241) 17.8 0.6%
0.2%
34%
Pradesh 99 (49-150) 6.4
Utar
Utarakhand
161 (143-180) 13.2 0.5%
Assam
Subtotal
EAGand (26-104) 3.6 0.1%
Pradesh 65 0.1% Abortion
Andhra 63 (16-110) 3.6 8%
0 0.2%
Telangana 92 (53-131) 4.9
Karnataka (10-77) 2.1 0.1%
43 Obstructed
(29-92) 3. 0.1% Haemorrhage
Kerala 60 labour
Tamil
Nadu 0.1% 5% 38%
(50-84) 3.6
67
South
Subtotal Subtotal 5.1 0.2% Hypertensive
75 (41-109) disorders
7.0 0.2% Sepsis
Gujarat 91 (43-139) 5% 11%
Or
Haryana (19-73) 2.6 0.1%
46 0.2% 11
Maharashtra
129 (56-202) 7.0 FIG.
(2003)
ed
(59-137) 5.0 0.2%
of maternal deaths in India
Punjab 98 0.2% Major causes
West Bengal (62-108) 4.5
ME 85
not add to 100
due to round-off)
Other states 4.7 0.2% (Figures may
83 (68-97)
Fo
Other Subtotal Source:(77) mortality in India
are as
of maternal
The determinants
Mer
Source: (76)
(150), Madhya listed in Table 16.
Rajasthan (164), Odisha Pradesh TABLE 16
UttarPradesh (197), following. Assam,
Madhya
closely reduction in mortality in India
cted Pradesh (173)
shown an acceleration
in Determinants of maternal
and Rajasthan have
(76). Social factors
last three years non-maternal Medical causes
of maternal and
The age
distribution
2016-2018 Special Survey
of Deaths are
deaths from the two-thirds of the Obstetric causes: Age at child birth
and
It shows that more than years. In Toxaemias of pregnancy
given in Table 15. 20-34 Parity
ality
are of women in age group distributed Haemorrhage Too close pregnancies
maternal deaths evenly
contrast, non-maternal
deaths are more years. Infection Family size
age span of 15-49 Obstructed labour Malnutrition
over the reproductive
Unsafe abortion Poverty
TABLE 15 deaths,
maternal and non-maternal Illiteracy
gnorance and prejudices
Age distribution of
ecid
India, 2016-18 Lack of maternity services
Non-maternai deaths
the
Maternal deaths 95% CI Shortage of health manpower
OUP
Age groupsProportion 95% CI Proportion Non-obstetric causes: Delivery by untrained dais
(9-10) Anaemia Poor environmental sanitation
stat
15-19 5% (3-7) 9%
(11-12) Associated diseases, e.g Poor communications and
11% cardiac, renal, hepatic
n e 20-24 33% (29-37) (12-13) transport facilities
(28-37) 12%
(12-14) metabolic and infectious Social customs, etcC.
25-29 32% 13%
30-34 17%
(13-20) (13-15) Malignancy
14% Accidents
7% (5-9) (17-19)
35-39 18% as "risk approach and primary
Newer approaches such right direction to reduce maternal
40-44 4% (2-5) (21-23)
22% in the
45-49 1% (0-3)
100% health care are steps Despite best antenatal care,
some
mortality and morbidity.
15-49 100% compications without warning signs
round-ofi) women may develop
gures may not add to 100 due to
Fig
Source (76)
 CHIL.DHOCD 647
MORTRLITY IN INFANCY AND
recommended
difficulties WHO has a
Y IN INFANCY AND
MORTALITY CHILD
DHOOD ecause of the above "stillbirth be appied to
any country the term over 500 g- the irtn
indicatorS to measure the level of nal within dead, and weighing with a gestation perioa
o
es are good TOeus born
associated tney
in dillerent counries. They also help
th case frequently however,
Mortai
sOCo-cconomic development of a
gnt mostBut for internationai comparison, which is more
th 3the overall weeks. boundary of 1000 g or more. 28 weeks.
in 5 cotelate well with tertain cconomic variables uggested a gestation period of
cNP Medical and soCial rogress have substantially tequently associated with a
mortality in
childhood STILLBIRTH RATE
uted of a foetus
custotnatry fo consider mortality in and widespread use of the term is. "death gestation)
he most of
equivalent to 28 weeks total birtis
ias becotne nummber of time petiods convenient
infancy n a weighing 1000 g (this is every 1000
a analytica and prugiammafic point of view as during one year in the
fom
both the o iore occurring stillbirths). Stillbirth rate is given by
UVe births plus
pcrinatal perjiod formuia
a. 100%0 gat birth
period Foetal deaths weighing over
carly neoiatal during the year x1000
neoatal period S:ilbth 1000 g at birth
late Total ive stillbirths weighing over
d
neonatai period duting the year
neonatal pericod countries. its
post in the developingtreatment of
t2s a frequent occurrence detection and
Tthese ate as tllustrated in lig 12 preventign involves the of pregnancy as well as of
inifectiou: patholoy in the couise conplication5. Rh
OETAL. DEAT1 Foetal death i death rior fo 1he high blood pressure 3nd its rupture of the
conyplete cAJLEIsiCa) Exlactian trom ilt mother of incompaibility, diabetes and prematueor impossible to
difficuit
podurt o ceptiM). 1 ctne o the duration of TiEmbtane. Some causes are
pregnancies. cord anomalivs,
by the iac thaf affen ch diminate. tiuch a* multinle
egriate: the death dicsled
wparation the ortus dact tof teaihe how any ofhet foetal malfotmations, piacenta anomalies in the
vudenee of life. suh teatig of the heaf. pultioti Aptimately 25 {79) million batries were stilborn tor
umbilcal cond, oúefunitc shovethent o fthe 209h in India. the SRS estimates
volintary
te year 201 wotkdw3cde 5 pr T0U0
death afier couniy was nlout
maseies 178 Defucd \eouly the ye 2018 fo the whole 7 fot the urban areas).
wwek of gertation {the defination f length
of getafion {5 fo the ual and
t silal ifh ievel of stilibirths has
varientwtween cnuntrie Among ihe igger state. thie highest Table 18 shows the
teen efitmated for Odisha (10).
Some obrCTVETS Hiave eme8d he
vie'w thaf vifal
sietstucal vepota aie iess reliabie on foctal
deaitha occuning 8tatewise breskup of fillbisth tate
compicted TABLE 18
a 29-27 wer k thiau N tthmse sccumng alfer 28
1he dala Paateiy Aor
Remats) tlity rates aod tilBirdh raten by redencd,
wecka, and have preiernei to 2lyze
4rlervals.. Stillluhs ale iiom teponed
he 19
Jndis and esinatnl metality tne Slbirth tate
Total Rural Urban
bigger states Uls Total utl rbat
Intant i0italit
India
Andhra Padesh
Posj neonalsl deatt 2
Asa 22 2 14
Biha
Kitattisgat 2
Dethi 3
uar 19 23
1Haryana 21 23
Neonali denth 4imachal Pradesh 6 17 11
Kashmir 13 10
Lateeonalal 3anu&
Jharkhand 18 20
death
Larly KaTsataka 8 22 10
Nanatal Kerala
dent Maditya Pradest 32
Maharashtra 5 2
Odisha 23 10
Punjab
otnatal death Rajasthan 28
Tamil Nadu 11
Telangan 15 18 10 2
Utar Pradesh 28 30 18 3 3
Utarakhand 24 24 25 8
k 1 Year 17
esatioBirth7Dy 28 Days West Bengal 17

Based un three year period 2016-18)

FIG.12 Source (69)
Mortaity in and around iniancy
 NEONATAL MORTAIITY RATE
649
sofperinatal mort rtality The neonatal mortality rate is tabulated as
two-thirds of all perinatal deaths occur among Number of deaths of children under
ut
with less
trhan 25 birth weight. The causes involve 28 days of age in a year X 1000
witnmplications
mor
in the mother during pregnancy
or Total live births in the same year
the placenta in the foetus or heonate.
r
abour,. n ti
:: The main causes ot death are intrauterine Causes of neonatal mortality
Main a low birth weight, birth trauma, and globally are as shown
birtn or neonatal infections. Ihe various causes of
tenin
he main causes of neonatal death
in ig 13.
may oe grouped as below :
atal mortality Preterm birth
complications
J
Antenatalcauses Intrapartum-related
35%
complications
Maternal diseases: hypertension, cardiovascular 24%
diseases, diabetes, tuberculosis, anaemia
Pelvic diseases: uterine myomas, endometriosis,
ovarian tumours Diarrhoea
131 Anatomical uterine anomalies, 1%
delects
incompetent cervix
Tetanus
141 Endocrine imbalance and inadequate uterine 1%
preparation
(5) Blood incompatibilities Other
(6) Malnutrition 7%
(7) Toxaemias of pregnancy Sepsis
(8) Antepartum haemorrhages 15%
Congenital
(9) Congenital defects abnormalities
Pneumonia
(10) Advanced maternal age 6% 11%
G}
Intranatal causes
FIG. 13
(1) Birth injuries
Global distribution of neonatal deaths by cause, 20188
(2) Asphyxia
(3) Prolonged effort time Source (83)
:

(4) Obstetric complications

No woman should die giving life. Nor should any mother
Postnatal causes endure pregnancy and childbirth, only to go through the
(1) Prematurity agony of having her child born dead or watching the baby
die minutes after birth. Yet for countless women around the
2) Respiratory distress syndrome
world this scenario remains a tragic reality. The first 28 days
3) Respiratory and alimentary iníections of life the neonatal period, is the mast vulnerable time for
(4) Congenital
anomalies a child's survival. In order to continue to accelerate progress
) Unknown in under-five mortality, focussing on newborns is critical.
causes
in some
Neonatal mortality is a measure of intensity with which
cases; the causes are not clinically ascertainable. "endogenous factors" (e.g., low bith weight, birth injuries)
eTventions for affect infant life. The neonatal mortality is directly related to
the reduction of perinatal mortality the birth weight and gestational age. Intrapartum related
Measures to reduce
perinatal mortality rates are essenia complications, low birth weight and preterm birth is a causal
decelerate the declining trend in neonatal
and inant factor in 60 per cent of neonate deaths.
alty rates. For further details, refer to lable 21.
Prematurity and congenital anomalies account for about
mational certificate of perinatal death 60 per cent of newborn deaths, and these often occur in the
first week of life. A further quarter of neonatal deaths are
Internaonal comparability, the 9th (1975) Revision attributable to asphyxia also mainly in the first week of life.
-

rnational
eCommend Sitication of Diseases (ICD-9) In the late neonatal period, that is, after the first week,
eath, Th a special certificate of cause of perinatal deaths atributable to _intection (including diarrhoea and
bulaCD has also a list of 100 causes (the "P" list) for tetanus) predominate. The importance of tetanus as a cause
uOn of perinatal

dention of
morbidity and mortalny
o of neonatal death, however, has diminished sharply due to
intensified immunization efforts.
perinatal mortality
page Neonatal mortality rates of bables born to mothers with
656 under
Preventive & Social Measures. no education are nearly twice as high as those of babies
NEONATAL MORTALITY RATE born to mothers with secondary education or higher. The
family's wealth and rural/urban residence also remain
Veriod, powerful determinant of inequities in neonatal mortality.
erCommen are deaths occurring during the neonatal Ending child marriage, reducing adolescent pregnancy and
Nong at birth and ending 28 completed aays
irth.in a extending birth intervals are crucial to reducing the risk of
S
oatal mortality rate is the number of neonata
year per 1000 live births in that year. newborn mortality.
 GERIATRIC
OBSTETRICs, PAEDATRICS AND rdre
650 REVENTIVE MEDICINE IN
be
vary from region to
Direct causes of newborn death as
urba
region. In general, the proportions of deaths attributed to
prematurity and congenital disorders increase as
neonatal mortality rate decreases, while the
the
proportions
tetanus
40
e
9in
rtrively
hi

caused by infections, asphyxia, diarrhoea and weight vary

decline as care improves. Patterns of low birth 2O
considerably between countries. Babies with a low birth able
first 20
weight are especially vulnerable to the hazards of the pear2
hours and days of life. particularly if they are premature.
Majority of low-birth-weight babies are not actually 10 tonal
premature but have suffered from in utero growth restriction, DIgge
usually because of the mother's poor health. These babies
too are at increased risk of death. tre
Neo Children Children Children Ch Under Children
The main causes of neonatal mortality are intrinsically natal aged aged aged aged tive aged
10-1
linked to the health of the mother and the care she receives 1-11
months
1-4
years years years
5-14
ears
zTonal
before, during and immediately after giving birth. Asphyxia Mortality rates 44
and birth injuries usually Tesult from poorly managed labour Odisha
and delivery, and lack of access to obstetric services. Many FIG. 14
neonatal infections, such as tetanus and congenital syphilis, Global mortality rates by age, 2018
can be prevented by care during pregnancy and childbirth. Source : (83)
Inadequate calorie or micronutrient intake also results in NeO

poorer pregnancy outcomes. It has been argued that nearly Sub-Saharan Africa is ten times more likely to die in the first
month than a child born in high-income country (83).
three quarters of all neonatal deaths could be prevented if
women were adequately nourished and received appropriate
care during pregnancy, childbirth and in the postnatal period. India
In India the SRS estimates for the year 2018 was about
However, neonatal mortality is the most difficult part of
18 per 1000 live births, in early-neonatal period (0-7 days),
infant mortality to alter, because of the endogenous factors with about 20 for rural areas and 10 for urban areas. Table
which are not sensitive to improvemenis in environmental
19 shows the early neonatal mortality rate and percentage
conditions. Neonatal mortality is greater in boys throughout
the world, because newborn boys are biologically more share of early neonatal mortality to intant deaths in the
fragile than girls. country and the major states. Among the bigger states,
TABLE 19
Incidence Early neonatal mortality rates and percentage share of
About 2.5 million newborns died before they are 4 weeks early neonatal deaths to infant deaths by residence
old and half of them died in their first 24 hours in the year India and bigger states/UTs, 2018
2018. 98 per cent of these deaths occur in developing Percentage of early
India and Early neonatal
countries. bigger states/UTs mortality rate neonatal deaths to
The global number of neonatal deaths declined from infant deaths
5.0 million in 1990 to 2.5 milion in 2018 -7,000 deaths Total Rural Urban Total Rural Urban
every day in 2018, compared to 14,000 in 1990. Neonatal
deaths accounted for about 47 per cent of all under-fivve India 18 20 10 54.6 56.9 44.9
deaths in 2018, increasing from 40 per cent in 1990 due Andhra Pradesh 15 19 7 51.7 57.1 31.9
to faster global decline in mortality among children aged Assam 92 15 16 8 37.237.2 37.5
1-59 months, than in their first month of life. Based on a Bihar 20 20 14 61.8 63.5 47.3
Chhatfisgarh 22 23 19 54.5 54.455.5
recent systematic review, abouta third ofall neonatal deaths
occur on the day of birth and close to three quarters die in Delhi 9 4 9 65.7 50.0 66.0
the first week of life. These findings suggest that focusing on Gujarat 15 18 9 52.5 55.2 45.7
the crítical period before and immediately following birth is Haryana 15 17 11 50.7 52.7 45.4
essential to saving more newborn lives (83). Himachal Pradesh* 10 10 6 50.9 51.1 44.9
Jammu& Kashmir 12 13 53.4 55.2 46.8
The mortality rate comparison for children under 15 Jharkhand 17 19 10 56.5 60.1 39.1
years of age is as shown in Fig. 14. Karnataka 12 16 54.2 62.7 35.7
In 2018, the neonatal mortality rate was estimated to be Kerala 5 4 64.7 56.5 79.5
at 18 deaths per 100 ve births globally. The probability of Madhya Pradesh 26 27 19 52.8 53.0 51.8
dying after the first month, in post-neonatal period was Maharashtra 10 14 6 52.7 58.6 40.1
11 per 1000, and probability of dying after reaching 1 year Odisha 24 25 16 59.9 60.7 53.3
of age and before reaching 5 years of age was at 10 per Punjab 9 9 9 43.2 40.6 47.4
1000 live births. Rajasthan 20 23 12 54.2 55.7 46.5
Tamil Nadu 7 10 4 47.9 57.2 35.7
The burden of neonatal mortality is uneven across
Telangana 13 16 9 49.3 53.2 40.9
egions. Some countries have relatively high neonatal
ortality given their level of under-five mortality. Most of
Uttar Pradesh 24 27 15 56.4 59.2 43.5
Uttarakhand 17 17 18 55.6 53.5 61.6
ese countries are in Southern Asia. Sub-Saharan Africa
West Bengal 12 13 9 53.2 55.7 44.3
ad the highest neonatal mortality rate in 2018, at 28 deaths
er 1000 live births, followed by Central and Southern Asia *(Based on three year period 2016-18)
ith 25 deaths per 1000 live births. A child born in Source: (69)
 POST-NEONATAL MORTALITY
RATE 65
All other remaining
Prematurity & causes 14%
Madhya Pracradesh (26), and Odisha (24) are the Injuries
(5), of early neonatal deaths to low birth weight 0.9%
The percentage 48.170
extrent deaths
deaths durin
during the year 2018, at the national Diarrhoea
3.1%
total infant4.6, and it varie from 56.9 in rural areas to
two

lpvel, has been as. In most of the states rural proportion is

Congenital
urban proportion. Amor anomalies
44.9in higher than the uroan 4%
relativer percentage for total varied from 37.2in
states, theDelh
gger
65.7 in elhi. Ill-defined
Assam to mortality rate in the country
Table 20
shows the neonatal or cause
percentage of neona deaths to infant deaths for unknowwn
and tne018, both at the national and
state levels. At the 5%
level, the neonatal mortality rate was 23 and
the Among
na from 14 in urban areas to 2/ rangesareas.
in rural
from 35 in
Birth asphyxia Sepsis
rangor states neonatal mortalitypercentage of neonatal & birth trauma
5.4%
the radesh to 5 in Kerala. The 12.9
Neonatal Other non-
Madhya Pra was 71.7 per cent at the communicable diseases
total infant deaths Pneumonia
deaths to from 60.1 per cent in urban areas 7.1%
el and varied areas. Among the bigger states 12 %
nationallevel. FIG. 15
74 4 per cent in rural highest percentage of neonatal
to
Odisha (79.4)
registered the deaths in India, 2017
the lowest was in Assam (51.4). Causes of neonatal
deaths, and
deaths to intan Source: (84)
TABLE 20 born with
rates and percentage share of neonatal country's total annual live births) being7.5 million
Neonatal mortality cent of the
residence,
deaths to infant deaths by 2018 2500 grams. Of these
bigger states, a birth weight less thancent are born at term after foetal
India and babies, about 60 per per cent are born
the remaining 40burden
Neonatal Percentage of growth retardation, while of preterm
fourth of global
India and
states/UTs mortality rate neonatal deaths to preterm, constituting one addition higher risk of
to being at a post-neonatal
bigger infant deaths births. Preterm babies in of
an increased risk
Total Rural Urban Total Rural Urban neonatal mortality, are at long-term neuro-developmental
71.7 74.4 60.1 mortality, stunting, and (80).
23 27 14
70.8 77.5 46.0 impairment during childhood
India 10
Andhra Pradesh 21 25 neonatal mortality
21 22 12 51.4 51.0 60.33 Interventions for the reduction of
Assam 20 78.7 80.1 66.3 mortality rates and to
Bihar
25 26
22 70.1 71.3 63.8 Measures to reduce neonatalenumerated in Table 21,
30
Chhattisgarh 29
8 10 74.8 100.0 74.4 improve newborn health are
10
Delhi
19 24 11 69.2 74.7 55.2
65.9 POST-NEONATAL MORTALITY RATE
Gujarat 2.5 75.1 one year
Haryana 22 24 16
68.4 68.6 63.4
28 days of life to under
Deaths occurring from deaths". death
13 13 9 The post-neonatal
Himachal Pradesh
17 18 14 75.4 76.3 71.7
are called "post-neonatal ratio of post-neonatal deaths in a
Jammu& Kashmir
22 14 68.0 71.2 52.6 rate is defined as "the number of live births in the same
Jharkhand
20 10 70.6 80.2 49.9 given year to the total a rate per 1000" (85).
16 79.5 year; usually expressed as
Karnataka 73.1 69.5
6 63.1
73.4 mortality rate is tabulated as
Kerala 71.8
38 23
Madhya Pradesh 35
18 8 68.4 74.2 55.6 The post-neonatal between
Maharashtra 13
79.4 80.2 72.5 Number of deaths of children
33 22 of age in a given year
Odisha 31
11 61.2 62.4 59.2 28 days and one year x 1000
13 13
Punjab
15 70.6 72.8 59.4 year
Rajasthan 26 29
65.3 76.2 50.8 Total live births in the same
14 6
is dominated by endogenous
Tamil Nadu 10 68.9
69.7 70.1
Telangana 19 21 14
73.2 75.8 60.9
Whereas neonatal mortality exogenous
21 mortality is dominated by
Uttar Pradesh 32 34
73.2 73.3 factors, post-neonatal
73.1 social) factors. Diarrhoea and
Uttarakhand 22 23 21
72.3 75.8 (e.g., environmental and
59.6 main causes of death during
West Bengal 16 12
respiratory infections are theMalnutrition is an additional
the post-neonatal period.
Based on three year period 2016-18) infections. In the
factor, reinforcing the adverse ettects of the
cause of post-neonatal
developed countries, the main Studies show that post-
Source: (69)

mortality is congenital anomalies.

CAUSES OF NEONATAL DEATHS IN
INDIA
shown in mortality increases steadily with
birth order, and
deaths are neonatal run a higher risk
e major causes of neonatal infants born into already large tamilies
Fig.15 that infectious diseases.
of all stillbirths and of death from
cent East Asia (including India), during
S estimated that 40 per during labour and the day of In some areas of South more frequently than boys.
deaths take place deaths occur post-neonatal period girls die
haal 75 per cent of total neonatal the of the female children in terms of
and about Notably half of all the maternal This is attributed to neglect
first week of life.
the nutrition and health care.
catns also take place in this period (80). mortality rate in
burden of low SRS estimates for post-neonatal
India accounts for 40 per cent of the global per The
birth babies (or about 30
weight babies with 7.5 million
 PAEDIARICS AND GERIATHIS
MEDICINE IN ORSTETRICS,
652 VENTIVE
TABLE 21
newtion healti
Priorily areas improe
to Eanka

Delayed child-bearing. and wanted pregnancies

I3efore and during pregnaney
Well-timed, well-spacedhealhy mother and alcohol
Wellnourished anddrug abuse, tobacco
Pregnancy free of immunization
Tetanus and rubella transmission of HIV
Prevention of mother-to-child land
dealan
Female education
health systems including:
Durng pregananey Early contact with
emergency preparedness complications
Birihand treatment of maternal complications
Early detection and well-being and timely interventions for foetal
Monitoring of foetal
Fordd
Tetanus immunízation anaemia and other STIs)
Prevention and treatment of infections (malaria, hookworm, syphilis transmission of HIU
Prevention and treatment of of mother-to-child
counselling and testíng, and prevention
Voluntary HIV
ars
Good diet women There
Prevention of violence against Evelso
by skilled attendant delivery and foetal complications
Safe and clean delivery management of has
Durtng and soon after dellvery prompt
Early detection and
Emergency obstetric care for maternal and foetal
conditions
IS
WEVeT,
ElODed
Newborn resuscitation warmth and cleanliness
Newborn care ensuring care
Newborn cord, eye and skinbreast-feeding
Early initiation of exclusive the newborn
treatment of complications of and/or complications
Early detection and too early or too small
Special care for infants born infections
Prevention and control of
transmission of HIV
Prevention of mother-to-child home care, danger signs and care seeking
Information and counselling on
Early post-natal contact breast feeding
During the first month of life and support of exclusive in newborn infant
Protection, promotion management of diseases
Prompt detection and
Immunization
14
Protection of girl child

Source: (86) RATE

INFANT MORTALITY
for
about 9 per 1000 live births
india for the year 2018 was rural areas and 9 for the urban (IMR) is defined as "the ratio
of

the whole country, and

9 for Infant mortality rate total number
break-up is shown in Table 22. in a given year to the
areas. The state-wise infant deaths registered same year; usually expressed
in the
of live births registered given by the
TABLE 22 rate per 1000 live births" (87). It is
20188 as a
estimates of post neonatal mortality in India, formula :
SRS
Post-neonatal mortality rate Number of deaths of children
State Rural year
Total Urban less than 1 year of age in a x 1000
11 IMR =
9 same year
Andhra Pradesh 8 22 Number of live births in the
20
Assam 10 6 important
Bihar 13 IMR is universally regarded not only as a most also of
12 of a community but
Chhattisgarh
9 indicator of the health status general, and effectiveness
people in
Gujarat the level of living of particular. Infant mortality is given a
Haryana of MCH services in demographers because : (a)
infant
Himachal Pradesh 12 separate treatment by mortality;
10 age-category of
Jharkhand 10 mortality is the largest sing of diseases
Karnataka 3 (b) deaths at this age are
due to a peculiar set exposed
adult population is less
Kerala 14 and conditions to which the affected rathe-
Madhya Pradesh less vulnerable; (c) infant mortality is programme
or
Maharashtra
quickly and directly by
specific health
Odisha change more rapidly than the general deats
Punjab
and hence may
11 11 rate.
Rajasthan 6
5
Tamil Nadu 11
12 14
International comparisons
Uttar Pradesh 8 5
has been a steady dec
West Bengal
6
During the past decades, there
(Table 23)
India in infantmortality
Dource : (69)
 MORTALITYRATE
INFANT
role.
services playing secondary this
medical countries,
TABLE 23 quality of life), with most of the developingdown. That is,
On the other
hand, in upside
mortality rate in elected countries
(1990-2018)
has been almost turned control of disease,
pattern mass the
hfant 1990 2018 medicalservices (e. g insecticides) have made the
and taking
Country mmunization, antibiotics and economic progress rates are
S8 32 with social mortality
India 18 major impact, Therefore, intant live births in many
25 supporting role 100 per 1000 only socio-
Sri Lanka 100
Bangladesh
106 57 reluctant to fall below It is now conceded thatprogress andd
countries. the
Pakistan 30 8 developing can re-accelerate
Thailand
78 37 economic development significant fall in infant
deaths.
Myanmar 42 7 lead to further
99 27
Infant mortality in India infant mortality rate countries
Chima
Nepal 9
New
Zealand
India is still among
high slowly from 204
IMR has declined
9
USA
in the year 2018). births in 1970 and
82 129 per 1000 live then
5 during 1911-15, around 127 for many years, and
to
down to
Japan 29 static at coming
World
63 remained once again to 114 in 1980 anddecline, the rates
baseline for MDGs
declineda bit Despite this significant
1990 is the 32 in the year 2018. developed countries (Table 23)
to births.
Source:783 in are high as comparedin the range of 3-7 per 1O00 live
countries or regions mostly
There are wide
variations between IMR for which are now differing populations.
The world average of country with widely
variations that existstate-wisesub
mortality. India is a vast among
the levels of intant at about 29 per 1000 live births. rate masks IMR
2018 has been estimated
per 1000 live births in the The all-India population. An examination of with
However, IMR varies from
4 groups of the variation,
per 1000 1live births in the
least shows a vast regional as low as 7 per
developed countries to 46 average in the South Asian for the year 2018 IMR of 48 and Kerala
developed countries. 1he infant Madhya Pradesh having Among the larger
per 1000 live births. Although thousand live births during the year 2018.Tamil Nadu, West
was 35 for the
countries
mortality declined
significantly, the drop was greatest States Kerala,
Maharashtra, Punjab, Karnataka, Gujarat,
lowest for least developed Andhra Pradesh,
Haryana, IMR below
developed countries and had a much greater Bengal, Jharkhand have achieved
world pradesh, and there is rural
countries. The developed to child mortality, Himachal
32. Within each state runs through
mortality compared national average of
reduction in infant reverse (83). the belt
critical infant mortalityChhattisgarh, Uttar
while in the developing
world the situation was urban variation. A Bihar,
200 or Assam,
The IMRs in
industrialized countries were around of the Odisha, Madhya Pradesh,all these states have infant mortality
ago. Even at the beginning Pradesh, and Rajasthan; average.
even more, some 150
years rates above
France, etc, had rates above the national
20th century. USA, UK, Japan, (1950) a spectacular mortality rates in major
states of
live births. Within 50 years By Table 24 shows infant
140 per 1000
in all developed countries.
fall in the rate was observed
achieved IMR rates below India.
1980s, most developed countries that in most TABLE 224 (2018)
Demographers opine rates in major states of India
10 per 1000 live births. IMRs would be Intant mortality
developed countries, further
decline in Urban
without some revolutionary advances in and major states/UTs
Total Rural
difticult to achieve mortality in India
in infant 21
perinatology. Any further reduction preventing one of its 29 33
will depend upon Andhra Pradesh 41 44 20
developed countries abnormalities.
namely, congenital Assam 32 32 30
principal causes,
mortality rates reflect the socio- Bihar 41 42 35
In general, the infant during the first Chhattisgarh 13
country. Deaths 13 3
economic development of a good health care. Delhi 33 20
preventable by 28
four weekS are largely developed and developing Gujarat 30 33 25
Much of the variations between explained by Haryana 20 14
WOrld in death among
newborn can be pregnant Himachal Pradesh
19
20
half of all 22 23
anterences in antenatal care about no antenatal Jammu & Kashmir 31 26
have 30
women in the least developed countries help of a Jharkhand 20
born without the 23 25
Care, and 7 out of 10 babies are factors being Karnataka 5
major 7
trained birth attendant. The other low birth weight Kerala 52 36
mother, 48
alnutrition and high parity of the Madhya Pradesh
19 24 14
of the baby, and congenital anomalies.
a to
Maharashtra
0 41 31
decline in infant mortality has been attributed of Odisha
20 21 19
The care, e.g., availability Punjab
0improved obstetric and perinatal labour, improved Rajasthan 37 41 26
OXygen, foetal monitoring during improvement in the Tamil Nadu
15 18 12
induction of labour (b) 27 30 21
iques for the
social progress (C) better Telangana
y of life, that is, economic and and 43 46 35
o of communicable diseases,chemotherapy, e.g., immunization antibiotics
Uttar Pradesh
31 31 29
Uttarakhand
(d) advances in 22 22 20
dration
and
e.g., emphasis on breast West Bengal
fsecticides (e) better nutrition,
e.g., birth spacing. 32 36 23
eding, and (f) family planning, India
in the decline
industrial world, the dominant factor progress (1.e,
e mortality was economic and
social
Source: (69)
 b54
TABEE 26
There is plenty of evidence to show that better control of
infant mortality is related to a wider spread of literacy
(particularly female hteracy) and primary health care Also,
the states with the highest infant mortality are also the states
Meonatal mov talkt
0-4 weeks 12montt tat
with the highest fertility. Table 25 illustrates the impact of the 1. Low birth weight 1
Drhoul die
above variables on infant mortality and prernaturity
2. Birth injury and d:fficuft labour
TABLE 25 3 Sepsis 3Othercemnuab
MR. fenale Hieracy rate andbirth Tate 4 Congenital anomalies iease
in major Indian States 5. Haemolytic diseases of newbsorn Malnutrtiesn

Birth rate 6. Conditions of placenta and cord 5 Congenitaí anoinat

IMR Female 6 Accidents
per 1000 literacy per 1000D 7 Diarrhoeal diseases
State 8. Acute respiratory inkections
live births Tate population
(2018) (2011) (2018) 9. Tetanus
59.7 16.0 The principal causes of intant mortality in India are
Andhra Pradesh 29
21.1 birth weight (57%), respiratory intections (17% dianhe
ASsam 41 67.27
diseases (4%), congenital maltormations (5% and
Bihar 32 53.33 26.2 infection (2%). birth injury 3) and unclassified abou
Chhattisgarh 41 60.59 22.5 (18%) (62). Neonatal deaths make a major contributien
Gujarat 28 70.7 19.7 infant mortality.Whereas in developing countries the
Haryana 30 66.77 20.3 high infant mortality is mainly due to low birth weighr, and
Himachal Pradesh 19 76.60 15.7 the combined effects of infection (e.g diarrhoea. raespiratns
56.21 22.7 infections) and malnutrition, in developed countries, it i
Jharkhand 30
17.2 mainly due to congenital anomalies, anoxia and hypoxia
Karnataka 23 63.1
Kerala 91 .98 13.9 Factors affecting infant mortality
48 60.20 24.6
Madhya Pradesh Infant mortality is due to the interaction of severai factors
Maharashtra 19 70.4 15.6 in combination. They may be classified as biclogicai
Odisha 40 .36 18.2 economic and social factors.
Punjab 20 71.34 14.8
24. 1. BIOLOGICAL FACTORS
Rajasthan 37 52.66
Tamil Nadu 15 73.86 14.7 (a) Birth weight
Telangana 27 16.9 Birth weight is a major determinant of infant and
Uttar Pradesh 43 59.26 25.6 perinatal mortality and morbidity. Babies ot low biuth weight
Uttarakhand 31 16.7 (under 2.5 kg) and high birth weight (over 4 kg) are at
West Bengal 22 71.16 15.0 special risk. Virtually, all infants weighing less than 1000 g at
poor
birth succumb. One major cause ot low birth weight is even
not only during pregnancy but
Source: (88, 89) maternal nutrition was
before that. It has been observed that the mother who has
years
adequately nourished during her own growing-up
Table 25 shows that Kerala has managed to surpass all baby even it
an excellent chance of delivering a normal sizepregnancy
the Indian states in certain important measures of social she has taken an inadequate diet during her An

development. It has the lowest infant mortality rate, the increase in birth weight would lower the perinatal and
lowest birth rate and the highest literacy rate. neonatal mortality.
(b) Age of the mother
Mortality pattern of the
account for There is a definite relationship between the age
(a) Age Deaths in the age-group 0-1 year mother and the fate of the child. Infant mortality the age
rates are
the country. About 71.7
10.5 per cent of the total deaths in
first month greater when the mother is either very young (below young
within the Very
per cent of infant deaths occur cent may die of 19 years) or relatively older (over 30 years).
(neonatal period) of life. Of these, 54.6 per the mothers also tend to be poorer and less educated (91)
risk of death is
during the first week of birth (69). The after birth. The (c) Birthorder
greatest during the first 24-48 hours expert obstetric order ot
The live births are classified according to their
problem is more acute in rural areas where rank. The highest mortality is found among
tirst born, and
in all developed countries,
care is scarce. (b) Sex: Whereas the lowest among those born second. The
risk of intants
female deaths, in India,
male death rates are higher than mortality escalates after the third birth. The
fate of the 5ts
(post-neonatal period) female
after the age of one month and later children is always
worse than the fate of the 3rc
than male deaths. Social deficiencies are
deaths are invariably higherphenomenon to social factors child. Infant mortality from nutritional
scientists have attributed this times higher for infants born with fifth or
higher birth orde
unfavourable to females in India (90). compared to the first three. These deaths
occur mostiy
post-neonatal period.
Medical causes of infant mortality (d) Birth spacing
The causes of infant
mortality are multifactorial. The influence on inta
Table 26 under two Repeated pregnancies exert a great anaemia in
nedical causes are shown in mortality. They cause malnutrition and
post-neonatal mortality.
ubdivisions neonatal and
 UNDER-5
MORTALITY RATE 657
death rate is a more retined indicator of the Leading causes of death age group
The cation in a country than infant mortality rate. It in the 1-4 years
The leading causes of death
sociathe adverse environmental health hazards are as shown in Table 28.
efilecalnutrition, poor hygiene, intections and accidents), TABLE 28
includ .
d, mannomic, educational and cultural characteristics
Mortality in this age group no longer depends L.eading causes of dealh in 1-4
years aye group
Developed countries
of the
ial hazards and other endogenous
first year e
factors, which
of life.
Developing countries
nRen cause loss
or hle during the Accidents
Diarrhoeal diseases Congenital anomalies
group 1-4 years, the second year is the period
Respiratory infections
n he206young chila runs tne nighest risk of dying. In the Malignant neoplasms
hen the Malnutrition
countries, death in the second year of life Influenza
loping Infectious diseases (C.gh
develol accounts for 50 per cent of all deaths between measles, whooping cough) Pneumonia
A vears of age. Atter the second year, death rates decline Other febrile diseases
siyely. The infectious diseases of childhood diarrhoea and
such
Accidents and injuries
whooping cough, diphtheria, group in
measles, in 1-4 years age
acute respiratory iniections alnect mostly this
age group, and The leading causes of death diseases and respiratory
lead to high case-iatality rate
in malnourished children. developing countries are diarrhoeal communicable diseases
can lea
about 30 some intections, closely followed by other with
Mortality rate at ages 14it is less than one in developed Such as whooping cough and measles. When combined
years is in
developing countries whereas diseases have high case fatality rates. In the
average, the malnutrition these
countries. The contrast is glaring. while on an infectious diseases are quite
developing countries than in developed countries deaths from cause of death trom the
IMR is 10-20 times higher in
rare, while accidents are the leading
average mortality rate between home accidents have been
the developed countries, the age of one year. Four groups of
the age 1-4 years is 30-50
times higher. (a) falls from unprotected stairs, and balconies
identitied- (d) poisoning. Almost all
In India, for the year 2018,
14 years age crude death (6) suffocation (c) burns and scalds
per cent of total deaths. Like preventable. The factors such as congenital
rate was estimated to be 1.l accidents are easy to prevent or to cure.
also shows wide are not
infant mortality, 1-4 year age mortality anomalies and neoplasms children in developing countries,
27. The states
state-wise variations as shown in
Table These conditions also affect
average are Madhya is overshadowed by infections.
reporting rates higher than the national but their relative importance
Pradesh 1.8, Haryana 1.5, Assam
Pradesh 2.0, Himachal
Jharkhand with 1.1 (69). UNDER-5 MORTALITY RATE
1.5, Bihar 1.2, Odisha 1.1 and
per cent followed by (Child mortality rate)
Kerala recorded the lowest with 0.7
Tamil Nadu with 0.6 per cent. UNICEF defines this as the "annual number of deaths of
as a rate per 1000 live
TABLE 27 children age under years, expressed
5
it measures the probability of
and births." More specifically, UNICEF
SRS estimates for child death (1-4 years) dying between birth and exactly 5 years of age.
uncler-live mortality in major states of India, 2018 considers this as the best single indicator
of social
per capita, as
Child death Under-five mortality rate development and well-being rather than GNP
State
(per 1000 live births) income, nutrition, health care and basic
(1-4 years) the former reflects
Urban education etc (98). The rate is calculated by the formula:
crude deathrateTotal Rural
Andhra Pradesh 1.1 33 37 Number of deaths of children less
1.5
than 5 years of age in a given year
ASSam X 1000
1.2 37 37 Child mortality rate
Bihar Number of live births in the same year
Chhatisgarh 1.1 47
Delht 1.5 19 Around the world, remarkable progress in child survival
31 21
has been made and millions of children have better fell survival
Gujarat 0.8 to 39
Haryana 1.5 36 39 30
chances than in 1990. The under-5 mortality inrate
23 17
deaths per 1000 live births in 2018, from 93 1990- a 58
Himachal Pradesh 1.8 dying
Jammu & Kashmir 0.2 23 4 20 per cent reduction. This is equivalent to I in 11 children
before reaching age 5 years in 1990, compared to in 26 in
1
Jharkhand 36 29
1.1
Kamataka 1.3 28 30 24 2018. In most of the SDG regions, the under-5 mortality rate
Kerala 0.7 10 was reduced by at least halt since 1990. The tatal number of
Madhya Pradesh 2.0 56 60 9 under-5 deaths dropped to 5.3 million in 2018 from 12.65
Maharashtra
0.6 22 27 million in 1990. On average, 14,520 children died every day
in 2018, as compared to 34,000 in 1990
45 35 (83).
|Ddisha 1.1
23 2
unjab 0.5 28 Despite progress over the past 2 decades, millions of
Rajasthan 43 newborns and children die every year, mostly from
0.8
lamil Nadu 0.6 17 preventable or treatable causes such as intectious diseases
elangana 0.8 35 and injuries. These deaths reilect the limited access of
38
Uttar Pradesh
0.9 47 19
children and communities to basic medical treatment of
Uttarakhand 3 infectious diseases, adequate nutrition, health interventions
0.6
WestBengal
1.1 such as vaccination, clean water and sanitation. Children face
Indla 36 wide-spread regional and income disparities in their chances
of survival. Sub-Saharan Africa continues to be the region
Based on three year period 20O16-18).
with the highest under-five mortality rate in the world 78
Source: (69)
 th4

PAEDIATRICS AND GERIATRICS

an
PREVENTIVE MEDICINE IN OBSTETRICS, wnnets thes
658
1child Causes of under five deaths elame
gether
deaths per 1000 live births in 2018. This translates to
in 13 dying before his fifth birthday 14 times higher than the Understanding the causes of child mortal pieunO
average ratio of 1 in 185 in high income countries and 20
times higher than the ratio of 1 in 263 in the region
ot
important public health insights. Ot the 5.3 millprovd
children under-5, that occurred in 2018, almost eaths ies
Australia and New Zealand. In 2018, about 30 per cent caused by infectious diseases and conditions such Espanded
38 per pneumonia, diarrhoea, alaria, meningitis,tetanus,
under-five mortality occurred in Southern Asia. About under-five de. HIU
cent of all deaths occur in least developed countries. The and measles. Around 47o of all deaths
in the neonatal period (within the first 28 days of oceurred 1he B
in Ted
ot with gender disparities in child mortality 1alp0x,
number countries
continues to decline. On an average boys are expected
to majority from preterm birth complications and intrap TEcent

have a higher probability of dying before reaching age 5 years related complications (complications durinoartum. r mHe
in 2018 was Globally, more than halt of the under-five -five do
than girls. The estimated under-5 mortality rate36 attributable to undernutrition (99).
deaths are
atlonal
41 deaths per 1000 lives birth for boys and deaths per tlnzalto/7gS
girls. In 2017, an estimated 2.9 million Worldwide, the leading causes ot death among chitd.
1000 live births for ldren 1mortalitg
boys and 2.5 million girls under 5 years of age died (83). under-5 years include pneumonia (12% of all under
yNENIaDledi
diarrho ve
A recent analysis showed that children in the
poorest deaths), preterm birth complications (16%), As ac
age of 5 intrapartum-related complications (11%), malaria (59
households are nearly twice likely to die before the a8
tetanus renont
as those from the richest. The risk of death in rural areas is neonatal sepsis (7.0%), meningitis (2.1%), Cross.end
1.5 times higher than for children in the urban areas and measles (2%), injury (6%) and others (12%).
Within urban areas children from poorer household
tend to comparisons show a wide variation among countries in the
have higher mortality rates. Children of mothers who lack proportions of under-five deaths attributableprogram to speci umple
indicate that optimal
any education are 2.6 times more likely to die betore variations
Such witely
causes. countr lnteg
reaching 5 years age. Poor air quality is another
risk tactor approaches for child survival will ditter from to hee Ad
for child mortality (97). country. Fig. 16 shows the causes of death of childr dren aeRW
alrnoea/
under-five in 2018.
Table 29 shows child mortality rate in some selected an
developed and developing countries. Summarizing data across regions and countries mac. malaria
nave
substantial differences in the distribution of causes of death hila
Approximately 90% of all malaria and HIV/AIDS deathsin
combins
TABLE 29
Onder-5 mortality rate in some selected 40g
children, more than 50% of measles deaths and about
imprcs

countries during 1990 and mid 2018 of pneumonia and diarrhoeal deaths are in the African e
enyirat
non EUmos
(Per 1000 live births) Region. On the other hand, deaths from injuries and
1990 2018 communicable diseases other than congenital anomalies DPalea
deaths in the
Country account for 20-30% of under-five region of omot
37.0 in the European and Western Pacific
India 126 the Americas and healin
21 7.0 Regions (100).
Sri Lanka
9.0
37
The steady improvement in under-five survival
is
Thailand 32.0
142 of advances. They include
Nepal
9.0 explained by a combination example, oral
China 54
30.0 developments in science and techonology (tor dehydration
144 and
Bangladesh
139 69.0 rehydration salts that treat diarrhoeal prevention),
Pakistan insecticide-treated mosquito nets tor malaria
9 4.0 (such as women's
UK
11 7.0 improved health-seeking behaviours skilled providers for
USA increasing use of antenatal care and
6 2.0 improved sanitation and
Japan
8 3.0 care around the time of birth), to prevent or
Singapore improved coverage of effective interventions
90 39.0 child mortality. Each one
World treat the most important causes of
Source: (5) Pneumonia 3%
Pneumonia 12% Preterm birth Neonatal deaths
complications 16% (47%)
Deaths among children
aged 1-59 months (53%)
Other 12%
Intrapartum-related
events 11%
Congenital 4%

Intrapartum-related events 1%-

Sepsis 7%
Preterm birth complications
2%
Meningitis 2% Other 3%
AIDS 1%
Injury 1%
Malaria 5% Congenital 5%
Injury 6% Diarrhoea Tetanus 1%
Measles 2% Diarrhoea 8%
0.3%
FIG. 16
among children under-5 by cause, 2018
Global distribution of deaths

Ource: 83)
 M
OF
Newborn and Childhood lllnesses (IMNCI),
INTEGRATED MANAGEMENT
nt of
Management have been produced that CHILDHOOD ILLNESS (1MC)
ols and idelines Integration 1
newborn issues; these are used to train field staff
Separate
integration has a long hístory, of different
ocus nsupervision a and monitoring purposes. The notion of complementarity o
for
and for
RMNCH+ strategy and in the year Supposed to tackle the needadminístrative structures, s0 as
year 2013, independent services and the goals were
In the
Newborn Action Plar were launched in view to goals. In 1950s, and in tne
9014, India
mortality rates in children. Newer vaccines were oetter achieve common outcome, in 1960s of prOcess
the aeined in terms of has diferent
reduood in the nat national immunization schedule. Please of economic impact. Integration level it means
introduced details. 99US levels. At the patíent it means that
efer to
chapter / for meanings at different of delivery one delivery
Global Strategy for Women's, Children's
and case management. At the point provided through
The (2016- -2030) and the 2030 agenda multiple interventions are opportunity to
cent's Health overarching vaccination is used as an efficiency and
Developme have three channel, e.g., where boostíng
Sustainable
for Survive, rive and Transform. The SDGs provide vitamin A to the child, integration means bringing
objectives - with SDG 3.2 system level sub-
ambitiou targets for hild mortality COverage. At the
support function of different
contain preventable deaths of newborns and children together management and complimentarity between
geking to end U5MR of ensuring health
year. These clude national targets of a
mortalityy
programmes and
of care. IMCI is now the only child three
der 5
more than 25 per 1000 live births and
neonatal different levels integration at these more
l000 live births (102). Target strategy that aims for improved adding
ate to no more than 12 per
ensure that all girls and boys levels simultaneously. More than just it has sought to
to channel,
42. which calls for efforts development, care programmes to a single delivery looks at the child care.
early childhood system
have access to quality
is likely to have an impact transform the way the health symptoms
and pre-primary
education; which
chances present with signs and
children's This overlap means
Most sick children
mortality, while also improving one conditions.
on child related to more than appropriate,
rewarding lives (102). may not be possible or
oflong and that a single diagnosis complicated by the need to
INDEX treatment may be of the
CHILD SURVIVAL and that
for several conditions. Surveys
combine therapy reveal that
intant and child survival is the management of sick children at these facilities
The basic measure
of
deaths under the age of are not properly assessed and treated and
Under-5 mortality (number
of many children quality care
births). A child survival rate per 1000 their parents are poorly advised. Providingchallenge. In
5 years, per 1000
live Under-5 that is a serious
births can be simply
calculated by subtracting the to sick children in these conditions UNICEF developed a
this figure by ten shows the these challenge, WHO and
1000. Dividing response to improved
mortality rate from
to the age of 5 years (103) strategy known as IMCI. The strategy combines nutrition,
percentage of those who survive with aspects of
mortality rate management of childhood illness disease prevention and
1000 under-5
immunization, and other importantobjectives are to reduce
The
Child survival rate =
10 health promotion elements. and severity of illness and
deaths and the frequency growth and
following table (Table 30) shows the child survival
disability and to contribute to improved
The
rates of some countries. development.
main components
The strategy includes three
TABLE 30 case-management skills o
(1) Improvements in the locally
countriees
health staff through IMCI the provision of
Child survival rates of some and through activitie
during 1990 and 2018 adapted guidelines on
2018 to promote their use;
Country
1990
(2) Improvements in the
health system required
illness; and
87.4 96.3 effective management of childhood
India community practice
97.9 99.3 (3) Improvements in family and
strategy is integrated ca
Sri Lanka
97.0
Bangladesh
85.6 The core of the IMCI problems, wi
85.8 96.8
management of the most common childhood
causes of death
i.

Nepal
86.1 93.1
a focus on the most important malnutrition. A guid-
Pakistan
94.6 99.1 diarrhoea, ARI, malaria, measles andthe guidelines, and
China 99.6 process of adaptation ensures that
99.1 go with them, reflect
UK
99.3 learning materials that tailored to fit
USA
98.4 epidemiology within a country and are systera
99.4 99.8
needs, resources and capacity of a country's health
Japan 99.7 are based on expert clini
Singapore
99.2 The clinical guidelines, which
opinionand research results, are designed for
children management of sick children aged l week up to 5 ye
in
the survival rates of tne
difference in
developing countries is a grim
pointer to
breast They promote evidence-based assessment
Thired
Third
and
World's ed for preventive services.
Through
immunization management, using a syndromic approach that supports
drugs. They inch
eeding, adequate nutrition, clean water, a rational, effective and affordable use of severe disee
rog mes, rehydration therapy and birth spacing, methods for assessing signs that indicate
oral be achieved. 1ne immunization, and feed
assessing a child's nutrition,
Virt
revolution in child survival could tertility at home; counse
inn WOuld be dramatic in humanitarian and
impact teaching parents how to care for a child
1erms.
 Rashiria
B childres
PAEDIATRICS AND
GERATHIC initta
O8STETRIS, will also be useful in anal rant for
birth
PREVENTIVE MEDCiNE 19 supervision These records programmes and provig a entionar disat
666 important. Children often and evaluating
school health
hone,
commng
school and the nmunity, including
Defects manage
ged
Attention to posture is also standing.uch useful linkbetween the fo
hem. while sitting and corrected. It is while
adopt bad postures observed and programme under itically lebe
us
tendencies, should bethat the major degenerative diseases School health evel
wIlwill
increasingly recognized early
health habits formedhealth Ayushman Bharat based
of adults have their
origin in poorexample public has been developed or DEIC cA
itions
smoking is an of a
schools. The programme irom a variety of
alohat the
anid
the
ensured
in life. Cigarette
should be tackled to learning and experiences interventions Two teachers litiesOncezero
problem that
2) Environmental activities and keep
young people
Health Encouragingtheir environmentf national school based
preferably one male and
one female, in
wellness Ambassadors
every
ns
ouildbe at
delivered
take part in health function of school health services. designated as "Health and seru
an important programmes, and evenn heath promoton and disease preventie
clean is
community health programnes trained to transact form interesting activities for on 0 FoVIsionof
Visits to observe action information in the of messages will also Hur iron
in community of health promotion
better participationfly control campaigns, construction 1or every week. These in the countr s Weekly will
e.g, vaccination, latrines) are excellent opportunities is on improving health practices Messengers age
services u
sanitary wells and (3) Family life Family life educafion bearing and welness the or
:

developed students will act as Health ars

health education. recognized as a priority in bofh service is ese
being increasingly health society (119). zachers
countries. The school of healthy lives
and developing the developmentf reproduction. Activities in school STOups
concerned nof only with attitudes towards human
but also with healthy the school Weekly health and wellne
Iness Entervention
is a function of transactions by
Health education in schools public health nurse Classroom
officer and the ambassadors
teacher. The health furnish teaching
assistant may
health worker/health the teacher is the key person in the Administration of IFA tablets
but
materials and advice, material to the children. To do this Fortnightly/Monthly
presentation of the health
should be well versed in Thematic school
assembly
important work, the teachersincerely interested in the weltare responses
education techniques, and parents the health Question box delia
take back to their Ervnce
of the pupils. Children in schools, and even
more
Quarterly
instructions they receive this Deworn
become adults they apply Thematic AHDs
important, when they families. In developing countries, Governme
knowledge to their own problem, "every school child is a Parent teacher meetings Febr
I0th
where i-health is a major Bi-annual Gewormi
health worker tablet (National
Administration of albendazole 400mg
11. Education of
handicapped children deworming day) gOvernn
child and
assist the handicapped maximum Wellness Ambassadors will facilitate will cor
The ultimate goal is to will be able to reach his The Health and programmes like
chíld school based
his family so that the a life as possible, to become
as
linkages with other ongoing coordinate referral of
Mer

potential, to lead as normal productive and RBSK; and be pro

to become a WIFS, NDD, MHS and treatment to the
independent as possible, and society. The resources for any support or quide
self-supporting member of the to country. students requiring Health Centres and Health & Wellness
child vary from country social and Adolescent Friendly students
information that the friendly
managing handicapped of health, welfare, Clinics. For any greater
It reguires the cooperation referred to the Adolescent
educafional agencies. require, they may also be district level.
health resource centres at the
records
12. School health School health promotion
activities
record of each student should be
A cumulative health
(a) ldentifying data be given a special
promotion activities will for
records should contain The health the students will
maintained. Such name and address, etc. appropriate health education
skills. The
name, date of birth,
parent's physical focus. Age behaviour and enhance physical,
record of findings of up to influence
(b) past health history
(c)
services be taken attention to
screening tests and record of records framework developed pays special developmental
enamination and maintaining school health psycho-social and mental aspects based on the
of
provided. The purposeinformation components are:
cumulative on the health aspects of stages of the child. The broad
to have intelligent health
is
school children in order
to give continuing
promotion
Age appropriate health High school
Middle school
Primary school Prevention of substance abuse
and related changes health
.Puberty Sexual & reproductive
growth and development hygiene
Health. safety Eye care, oral .
Violence prevention
Personal Nutrition .Unintentional injury
activíty
Nutrition and physical Bullying prevention
.Road safety
Hygiene practices and yoga
like .Meditation Nutrition
Prevention of diseases Internet safety and media literacy
Meditation and Yoga
malaria, dengue, TB, .Prevention of substance abuse
diarrhoea and
worms infestation, ADS
vaccine preventable
diseases .HIV
Mental health
 screening (719
HANDICAPPED CHILDREN 667
Health Upgrading skills in emergency care
riya Bal
Swasthya Karyakram (RBSK)
Rashtrtiative aiming at early identification andis an A child spends a considerable part of the day in school,
importa in
hildren from birth to 18 years to cover early which makes it the responsibility of the school to ensure the
rventiot birth, 4 'D's
Deficiencies, Diseases, Development safety of all children in every possible way during their stay
Detects
viz. luding disability. The 0-6 years age group, will at school. Thus students and teachers should know the basis
delays be aid and should be able to respond to emergencies.
cally managed
Specifical trict Early Intervention
Center irst
There should be a first aid box available in each school. he
level
DEIC) for 6-18 years age group, management
while fo
of teachers and students will be made aware of the var0us
nditions will be a done through existing public health
lacilitie DEIC
will act as referral inkage tor both Services available in each school to emergencies like the
the age ambulance, fire brigade, police, closest health facility, etC.
Once the child screened and referred from school,
i

goupho
twould ensured that the necessary treatment/intervention essions of the basic first aid will be taken up and linkage
lelivered at zero cost to the family. with local disaster response team will be made, to build the
s capacity of school teachers and children to respond to
Provision of services (119) emergencies.
eekly iron folic acid supplementation through 6-19 School health administration
aae will follow
yearsfof age
i the existing guidelines in the schools. The health of the school child is the responsibility of the
ese services will ntinue to be delivered through school parents, teachers, health administrators and the community.
teachers. The success or efficiency of school health service depends
largely on effective coordination between the participating
Age group
6-10 years 10-19 years agencies. There is no uniform pattern of school health
Intervention Tablets of 45 mg Tablets of 100 mg administration, both here and abroad. In England, school
dose elemental iron and elemental iron and health service is part of the Education service of the country.
400 meg of folic acid 500 mcg of folic acid In India, school health service is administered by different
Weekly, throughout Weekly, throughout
departments in different States these are usually the
Regime
the period the period departments of Health and Education. The School Health
6-10 years of age 10-19 years of age Committee set up by the Government of India, in 1960
recommended that school health service should be an
Service delivery Through teachers Through teachers integral part of the general health services. The general
health services in India are administered largely through the
Deworming To combat parasitic worm infections,
primary health cemtres in the rural areas, where the bulk of
Government of India has declared 10th August and India's population lives. School health service is, therefore,
10th February as fixed days to provide Albendazole
tablets for an important function of the primary health centres.
deworming school-age children. During NDD, Albendazole
400mg chewable tablets will be administered to children
at (a) Primary health centres
government, government-aided, and private schools. This The primary health centres are charged with the
will continue to follow
the current NDD guidelines. responsibility of administering school health service within
Menstrual hygiene management: Sanitary napkins may their jurisdiction. It requires a whole-time, medical officer to
be provided in the schools for
adolescent girls as per MHS cOver 5,000 to 6,000 children a year. The School Health
guidelines. Committee (1961) has, therefore, recommended that the
Heaith screening staff of the primary health centres should be augmented by
Under RBSK, identification of additional staif to carry out effectively the school health
30 diseases including
malnutrition and anaemia with programme.
appropriate referrals. ldentification of children with
relractive errors may be done
and spectacles provided. (b) School Health Committees
Physical and mental
fitness Classes on yoga and The School Health Committee (1961) in India
meditation through Health &
Wellness Ambassadors may be recommended the formation of school health committees at
promoted on the lines of 'International Yoga Day' to
the village level, block level, district 1level, state level and
nculcate the habits of yoga and meditation among children national level. These Committees should mobilize community
since their
childhood. resources and make the school health programme continuous
Research and self-supporting. The National School Health Council will
Provisions may be made for research and
sudies on health, wellness
and nutrition for children to be an advisory and coordinating body.
a5ess the impact
of the programme.
HANDICAPPED CHILDREN
er preventive services in the form of regular age
PTiate
are being vaccination of children through local health staff
Definitions
considered.
"Handicap" may be defined as "reduction in a
lectronic health person's
records capacity to fulil a social role as a consequence of
a
impairment, inadequate training for the role, or
Ish student.
each envisaged to develop an electronic health record for
circumstances. Applied to children, the term usually refers
othe
Student Health Card will "include health t
eening and
service access data for each student. Under the presence of an impairment or other circumstances tha
chidro the screening and referral records of all the school are likely to interiere with normal growth and developme
or with the capacity to learn" (120).
losch be digitalized.The relevant information related
International Classification of Impairments, Disabiliti
Tecordenealth activities will be added to existing electronic
Ords maintained and Handicaps (ICIDH): First published by WHO in 198
under RBSK.
 676 PREVENINE U MCINI IN (MSTLRAS, PAEDIATRIGS AND GERIATHES

trasler, a
harbouring or neceipt of child for the purposeof Strengthening the capacity
ENploitation. A clhilkl tralticker is anyone who contribules to communities to care for and
n chment of the traflicking process with the intent to rotect chiidror
Nploit the child. This included those wlo play only a part in
Government commitment
to
providing budgetary support chit
the entire process, suclh as recruiters. intermediaries,
document proviclers, Iransporters, currupt officinls, service policies targeted at the most and
excludod
uded
provilers and unscrupulous employers. Girls are lralficked children. and
Ratification and implementation irrads,
disroportionately for comercial sexual exploitation and
child domestie labour. The lLO 2005 Glolbal national and internation of gislatten,
Report concernir
estimales that Asia has tlhe highest number of child rights and protection.
ratticking victinms followed by industrialized
countries, Latin Prosecution of perpetrators of
America and Caribbean, the Middle East Countries (132).
and avoidance of criminalizingcrimes ac
against
child victims. chldton
"Poverty-plus" at source, transit and destination: Poverty
An open discussion by civil
alone does not guarantee that a child will be trafficked, attitudes, prejudices, belief
society and
d the
usualy it is poverty plus one or many
the. mesa
other risk factors that facilitate or lead to abuses. and practices es
make a child vulnerable to traflicking. These the
individual, household, community or
could be at the Ensuring that children know
institutional level. their rights
Some common causes of vulnerability include encouraged to express them and
lack of birth
TCgistration, discrimination, orphanhood,
illness in the
skills and information to are aiven
protect themselyo- r
family, family abuse, conflict or natural abuse and exploitation.
disaster, travelling
alone or through a non-registered agency or Availability of basic social
inability to speak the language, smuggler, services
unregulated informal without iscrimination. to all chitl
children
economy. weak legal framework
corruption and a large youth population
and enforcement, Monitoring, transparent reporting
market absorption. Vulnerability is not static,with low labour
it changes over abuses and exploitation. and oversicht
e
time, and different risk
factors are present in different The key to building the protective
contexts (132). responsibility of members of the environment is
Trafficking of children takes many society, by ensurine
children are not exploited. While families
children are forcibly abducted, othersdifferent forms. Some
are tricked and still the primary responsibility for protectingand the State
children, ongeir
a
others opt to let themselves be trafficked by promise of and sustained efforts by individuals and organizations at
earnings, but not suspecting the level of levels, are essential to break patterns of
will suffer at the other end of exploitation they abuse.
the recruiting chain. Trafticking UJJAWALA: "Ujjawala", comprehensive
always involves journey, whether a scheme to
across the international border. within the country or combat trafficking was launched in India by
the Ministry c
The relocation takes Women and Child Development on
children away from their families, communities 4th December, 2007
net-work, leaving them isolated and utterly and support and is being implemented mainly through
NGOs. The
exploitation. Collecting data about these vulnerable to scheme has five components ot
children is very prevention, rescue
difficult. It is estimated that trafficking rehabilitation, reintegration and repatriation
1.2 million children each year. affects about trafficked for commercial sexual exploitation. of victims
Some of the
Though the trafficking of children is a provisions under the scheme are (65) :
some dominant regional patterns areshadowy practice, (1) Formation of community
identifiable. In vigilance groups, adolescents
West and Central Africa, children are "placed" in a marginal groups, awareness creation and preparation
position within other families. This practice is being of IEC
used to material, organizing workshops;
exploit children both within and outside home. Children (2) Safe withdrawal of victims
also trafficked into plantations and mines, are from the place of
and in those exploitation;
countries affected by conflict, they are directly
militias. In East Asia and Pacific, most traffickingabducted by (3) Rehabilitation of victims by
providing them safe shelter,
is into child
prostitution, though some children are also recruited basic amenities, medical care, legal aid, vocational
for
industrial and agricultural work. In South Asia, trafficking training and employment;
forms most of immense child labour problem (4) Re-integration of victims
in the sub- into society; and
continent, often related to debt bondage. In addition,
(5) Provide support to cross-border
significant number of children are trafficked for victims for their safe
other repatriation to the country of origin.
purposes, including into prostitution, carpet and garment
factories, construction projects and begging. In Europe,
children are mainly trafficked from east to west, reflecting
Preventing Violence Against Children (133)
the demand for cheap labour and child prostitution in richer Globally, it is estimated that
one out of two children age
countries of the continent. Children are also used as 2-17 years suffer some form of violence each ye=
unskilled labour and in the entertainment sector. Worldwide, close to 300 million
children aged 2-4 yea
regularly experience violent discipline by their caregivers
An estimated 8.4 million children work under terrible
third of students aged 11-15 years worldwide
circumstances and are forced into bondage or other forms of have bE
bullied by their peers in the past month,
slavery (Fig. 19). and 120 mill
girls are estimated to have suffered
Making children safe requires creating a protective some form of tor
sexual contact before the age of
environment for them. The key elements of a protective 20 years. Emotic
violence affects one in three children and worldwide on-
environment include: four children lives with a mother who is the victin
 67:7
xtner violence.
partn An estimatec 40,150 children programmes
ntimate micide in the year 2017. Community mobilization
vere victims of The
dided ate for 0-17 years old was 1.7 per 100,000 By-stander interventions
hal
gotbra hond the rate for boys ot 2.4
per 100,000 was Safe Reducing violence by addressing
poulatio
girls (1.1 per 100,0O0 population). environments "hotspotss
vicethan in The Interrupting the spread of violence
pandemic and socielies resjponse to it has had a
cOVID
on the prevalence of violence against Improving the built environment
tic impact likely to
childrer and
is have long-lasting negative Parent and Delivered through home visit
onsequences. caregiver Delivered in groups in comnmunity
their lifetime. children exposed to violence are at Support settings
Delivered through comprehensive
dTisk of mental illness and anxiety disorders; high
incneas programmes
viours ike alcoho and drug abuse, smoking and
risk chronic diseases such as cancers, diabetes and Income and - Cash transfers
unsa o3ase:
infectious diseases like HIV; and social Group saving and loans combined
arems including educational underattainment, further economic strengthening with gender equity trainingg
vement in violeng and crime. The economic costs of Micro-finance combined with gender
consequences are enormous. norm training
these
The elimination
of violence against children is called for Response and - Counselling and therapeutic
ceveral targets of the 2030 Agenda for Sustainable Support services approaches
Screening combined with
in
mevelopment Goals. specially in Target 16.2: "end abuse,
nloitation. trailicking and all lorms of violence and torture interventions
o children. It focusses on inierpersonal violence which - Treatment programmes for juvenile
caunts for most acts of violence against children, and offenders in the criminal justice
nrludes child mal-treatment, bullying and other types of system
vOuth violence and intimate person violence. The - Foster care interventions involving
cOvernments can monitor their progress towards reaching social welíare services
he SDG over course of 2020-2030, through the lens of Education and Increase enrolment in pre-school
Seven INSPIRE evidence-based strategies for ending life skills primary and secondary schools
violence against children. Establish a safe and enabling school
environment
INSPIRE: Seven strategies for ending violence Improve children's knowledge about
against children (133) sexual abuse and how to protect
INSPIRE is a set of seven evidence-based strategies for themselvesagainstit
Life and social skills training
and communities working to eliminate violence
-
countries
against children. Launched in 2016, INSPIRE serves as a
- Adolescent intimate partner violence
technical package and handbook for selecting, implementing prevention programmes
and monitoring effective policies, programmes and services
to prevent and respond to violence against children. and violence against
The COVID-19 pandemic
INSPIRE is an acronym, with each letter representing a children (133)
stategy: for the implementation and enforcement of laws;
1

N for
norms and values; S for safe environments; P for
The COVID-19 pandemic and societies response to it
parent and caregiver support; I for income and economic
affects all aspects of our lives. School closures have
sirengthening: R for response and support services; and impacted some 1.5 billon children. Movement restrictions.
E for
education and life skills. There are also two cross loss of income, isolation, and overcrowding have heightened
CUting activities (multisectoral action and coordination, and
levels of stress and anxiety in parents, caregivers an
monitoring and evaluation) that connects the seven
children, and cut families and individuals off from thei
Stategies and monitor the extent of their implementation
usual sources of support.
and impact on the problem. These consequences have altered the prevalence an
patterns of interpersonal violence. Decreases in homicide
he startegies and approaches of INSPIREareforaspreventing
follows and violence-related injuries receiving emergency medici
d Tesponding to violence against children treatment (which mostly involve older adolescents and adu
Strategy males) have been reported, particularly where lockdow
Approach were accompanied by bans on alcohol sales. Spikes in ca
mplementation of
Laws banning violent punishmentother to helplines about child abuse and intimate partner violen
and enforcement
children by parents, teachers or have been observed, alongside declines in the number
l laws caregivers child abuse cases referred to child protection services.
Laws criminalizing sexual abuse and increase in potential or actual online harms, including sex
exploitation of children exploitation and cyber-bulying resulting from increa
Laws that prevent alcohol misuse internet use by children, has also been identified.
e Laws limiting youth access to economic devastation wrought by COVID-19 and
lirearms and other weapons response to it may take years to overcome, and co
Norms exacerbate economic inequalities, poverty, unemploym-
and Changing adherence to restrictive
values and household financial insecurity.
norms
and harmful gender and social
 SOCIAL WELFARE FRtiGHAMME 681
Supplementary nutrition (therapeutic
.of manhildren sutfering from
2nd and 3rd degree Nutrition Programne for Adolestent Girls was approved1s
n
iutrition Children sutfering
irom 4th egree malnutrition
nded hospitalization.
ne year 2009-10, on a pilot project basis. The project
ng implemented in 51 identilied districts from the major
es. Undernourished adolescent girls in the age group o
health education 19 years (with body weight less than 30 kg in the age
ritjion and
to
group ol 11 to 15 yeats and 35 kg in the age group ol
\utrition pducation and health education is given to all kg of Iree 100d
the age
group 15-45 years. giving
priority to ars) is are covered under the scheme. 6per month. ne
Npectant mothers. It is imparted by grain provided to cach beneliciary
specialiy programme is being implemented through the administrätive
singcourses in Village during home visits by
workers. Set-up ol ICDS scheme at the state, district, block and
ganwadi Anganwadi Centre level.
Inmunization
Poshan Abhiyan (138)
ization of children against9
325 is being done,
vaccine preventable
while for
expectant mothers. overnment of India has launched "Poshan Abhiyan" on
commencing
oth December 2017 for a period of three yearsare
ization against tetanus is recommended. irom 2017-18, in all 36 states/UTs. The goals to achieve
Health check-up improvement in nutritional status of children from 0-6 years
adolescent girls, pregnant women and lactating mothers With
This inchudes (a) antenatal care of expectant mothers; fixed targets. It ensures convergence of various programmes
nOsthatal care of nursirng mother and care of newborn
anis (c) care of children under 6 years of age. Besides
i.e anganwadi services. Pradhan Mantri Matru Vandana
Yojana; schemes for adolescent girls of Ministry of Women
munization. expectant mothers are given iron and folic and Child Ddevelopment; Janani Suraksha Yojana; National
tablets along with protein supplements. A minimum of Health Mission of Ministry of Health and Family Welfare
abusical examinations are done. High risk mothers are Swachh Bharat Mission of Ministry of Jal Shakti etc.
ared to appropriate institutions for special care.
The objectives and targets are as follows (138):
The health care of children under 6 years of age consists 1. Prevent and reduce stunting in By 6 per cent
children (0-6 years) (2 per cent/ year)
1. Record of weight and height of children at 2. Prevent and reduce under nutrition By 6 per cent
periodical intervals; and underweight prevalence in (2 per cent/ year)
2. Watch over milestones; children (0-6 years)
3 Immunization; 3. Reduce the prevalence of anaemia By 9 per cent
4. General check-up every 3-6 months to detect among children (6-59 months) (3 per cent/ year)
disease, malnutrition etc.; 4. Reduce the prevalence of anaemia By 9 per cent
5. Treatment for disease like diarrhoea, dysentery, among girls and women in the (3 per cent/ year)
respiratory tract infections etc. which are widely age group (15-49 years)
prevalent 5. Reduce low birth weight By 6 per cent
Deworming: (LBW) (2 per cent/ year)
1. Prophylaxis against vitamin A deficiency and
The Abhiyan aims to reduce malnutrition in the country
anaemia, and through a life cycle approach.
8. Referral of serious cases to hospital has also been
provided for. Twomore schemes are being implemented at the ICDS
level. They are (a) Rajiv Gandhi Scheme for Empowerment
Health records: Health records of the children, antenatal of Adolescent Girls "SABLA" for the age group 11 to
aTe
and delivery card etc. are maintained. A card 18 years to improve their nutritional and health status; and
0ntaining the health (b) Indira Gandhi Matritva Sahyog Yojana (IGMSY), under
mother.
record of the child is given to the
which conditional cash transfer will be made to pregnant
>.
Non-formal and lactating mothers in order to inmprove their nutritional
pre-school education and health status (65).
Cldren between the ages 3-6 years are imparted non At the end of 2019, about 7,075 ICDS projects and
H
pre-school education in an anganwadi in each 13.77 lakh Anganwadi Centres/Mini-Anganwadi Centres
ge with about 1000 population. The objective is to were functional in the country. About 305.09 lakh children
dOpportunities to develop desirable attitude, values
andbehaviour are pre-school education beneficiaries and 836.25 lakh
pattern among children. Locally produced supplementary nutrition beneticiaries are children
nnd e toys and material
are used in organizing play pregnant and lactating mothers. and
creative activity.
The administrative unit of an 1CDS project is
emes for "community development block" in rural areas, the
adolescent girls (65) the "tribal
present, there development block" in tribal areas and a group of
slums
"Kishori are two schemes for adolescent girls viz. urban areas. In selection ot project areas preference in
Adoleseakti Yojana"
aolescent
Girls"
and "Nutrition Programme for given to areas predominantly inhabited by backward was
backward areas, draught prone areas and tribes,
shori Shakti areas in which
ntrastructurTe Yojana is being implemented using the nutritional deficiencies are rampant. The
nthe rural/urban
of 1CDS. The
heme targets adolescent girls has a population of 100,000 and a tribal project project
self do.oup of 11 to 18 years and addresses their needs 35,000 population. The number of villages in about
umeric pment, nutrition and health status, literacy and the rural
project may be 100 while in tribal areas, it may
cal skills, vocational be only
skills etC. about 50, taking into account the difticult terrain in
which
 A
IN OBSTETRCS PAEDAII
682 REVENTIVE MEDICINE High rate of pregnancyand
mortality morbidity has
childbirth in pubertalbe
aeP
for the and
located. The focal point associated with
problem is now compoun an ot
the tribal projects are early childhood services under the adolescent girls. This number of pregnancies, by tiltcatrcnam
delivery of integrated trained local woman known as the
dramatic rise in among both
ICDS scheme is the functionaries in the 1CDSis adolescents, who are also havi ato bealth de
Anganwadi worker (AWW). Other and unwanted, contracting sexually an tran cialnc
Project Officer (CDPO), who more abortions and appears also to be sitto
are the Child Development(Mukhya Sevika) and 100 AWWs. more often. Ihere
prracneS
ntarmin7
in charge of 4 Supervisors
diseases and abused childron sei
for 20-25 anganwadis and the number of abandoned av
nt
Each Supervisor is responsible in record keeping, visits of adolescent mothers. As long as these problems are lovied ociety
acts as mentor to AWWs; assists
community visits; and the energy, creativity and ideal needs
health personnel and organizing Anganwadi worker to persist, much of to society. wever, the probler of Advoca
to AWWs. youth will be lost rns are
provides on-the-job training the community. efforts to eliminate them must invol PrOgran
is the multipurpose
agent, selected from preventable, and Contribufing in ways apnye he
link to children and mother; assists young people themselves, health
AWW provides direct beneficiaries; organizes cultures.
CDPO in survey of community and to their particular Using
non-tormal education sessions;
provides health and Society today demands more of young people tha. knowle
mothers;: assists PHC staff in of the extended family eater
er
nutrition education to
maintains records o before. With the decline them, especially in the factor
providing health servicesS attendance; liaises autonomy is expected of and industrial of
sexua
immunization, feeding and pre-school health staff annd children; increasing urbanization beha
with block administrator, local school,
means that economic independence
is achieved0n
based activities, training. Early paronsOnly
community, and works for other community through more education andlimit nthood,
e.g., family planning.
committed to child particularly for girls, may or preclude social
ability to achiero
s
The Government of India is is steadily expanding educational development and the greater morbidit
Mob
with
development as a policy priority and of reaching every
status in society and is assoCiated Survey observed an i and E
20
ICDS programme with the ultimate aim mortality. The World Fertility se app
programme on the lives fertility and the education of wornen:
child. The impact of the crucial indicators relationship between average, twice as man Fac
of children is evident in several
malnutrition, women with no educafion have, on
increased birth weight, reduced incidence of
children as those with seven or more years of schoolin
and a reduced
increased immunization coverage, are of
by the Corollaries of this finding the ncreased earning power
infant and child mortality rate in areas covered status within the fami PRE
educated women, their improved are able to exercise over tthei
ICDS (118). and the greater control they Age
own lives.
Health of adolescents A more universal consequence
of early and more
as including Slerin
The term "adolescence" has been defined as those frequent childbearing is the increase population size and
in
piotecs
10 and 19, and "youth at 16, the age gap between
those aged between term that covers growth rate. Where girls marry
between 15 and 24; "young people" is a may be less than 20 years; this gan actth
ages of 10 and 24. successive generations
both age groups, i.e. those between the
may widen to as much as 30 years where
the age at shoulc

True adolescence, however, being the period of

physical,
psychological and social maturing from childhood
may fall within either age range.
adulthood,
development that takes place in adolescence is generally
uneven, in that physical maturity may well be achieved
or social maturity; in
advance of psychological
societies, in fact, reproductive capability is now established
at an earlier age than in the past.
The importance of the health of adolescents has started
to receive increasing recognition, particularly in developing
countries where four out of five of the world's young people
dive, and where more than half the population is under the
age of 25. These young men and women are, or will
ecome, the parents of the next generation. They must be
given every opportunity to develop to their full potential as
ealthy individuals.
Because adolescents are less vulnerable to disease than
ae very young and the very old, health problems specific to
eir age group have been given little prominence until
now.
oreover, in societies where girls in particular have
aditionally married at an early age, adolescence has been
garded merely as a brief interlude between puberty and
arriage. As the average age of menarche has fallen, and
h an increasing trend towards late marriage, however,
this
iod has been extended and traditional attitude has begun
hange. At the same time, the influence of the family has
lined, urbanization and migration have become more
mon, and young people have been increasingly exposed
he mass media all factors that contribute to major
ges in social and sexual behaviour.
reproductive phenc
to marriage is 25. The sexual behaviour and
patterns of young people are highly susceptible to social chan
The The
influences and related to their own sense of psychological
well-being. gEtlc
in
most Although an adolescent girl is likely to give birth and rear
family, the
her children within the context of an extended
risks she and her children run ot illness, injury and death are
woman
far greater than those for a mature in her twenties.
of anaemia, developing during pregnancy, and
The chances
of retarded fetal growth; premature birth and complications
during labour are all significantly higher for the adolescent
mother, as are the risks of her own death during pregnancy
or child-birth.
Formal education of girls generally ends with marriage,
and from then on their social status may well depend on
fecundity. An adolescent girl who proves to be infertile (or
whose husband is infertile) runs the risk of being rejected by
both husband and family and thus of losing what little status
she has. The second major set of problems of reproductive
health in adolescence results from the profound socio-
economic changes taking place in most developing
countries. The average age of menarche has fallen, there is a
trend towards later marriage, and young people are often
less directly supervised than was the case in the past all of
which have the effect of increasing the opportunities tor
sexual encounter. Since the subject of adolescent sexuality
remains taboo in most societies, there is widespread
ignorance among young people of the risks associated with
unprotected sexual activity. Sources of information and
 PRIVENIIVE MEDICNE ANO
CiERIATRCS 683
are
advice are rarely ilable or accessible to increase. These trends
people is continually on the medical services
pflve Od and social
addition impulsive sexu behaviour and non-use appearing in all countries where living is high
of
aceptives aressometimes exacerb by alcohol and are well developed and the standard million old
estimated 694
use. In the year 2019, there were an were livingin
million
sher of major approaches
to reducing problems by ersons in the world, of which 540Japan have the highest
ation of the contributing factors will serve to promote developing countries (5), Italy and per
24 per cent and 16
oalth among the young and thus to improve health proporion of older persons (about By 2025, the number ot
ial development of their communities. These cent respectively in the year 2019). than 1.2 billion with
ches include the following clderly people is expected to rise more countries. In India,
low-income
about 840 million of these in
nforming, educating and sensitizing key groups in
although the percentage of aged persons to the total
Ociety to individual health and social development developed countries,
population is low in comparison to the population 15
needs.
nevertheless, the absolute size of aged
9.3 per
Advocating appropriate policy, legislation and
reproductive Considerable. For the year 2019 the estimates are: years.
adolescent age of 65
cent of total population were above theIndians, brings with
programmes for promoting
health. This profound shift in the share of older
Using appropriate and innovative research
to improve healthcare policy
it a variety of social, economic and
knowledge ot, and disseminate intormation about, the challenges (141).
factors that intluence and determine young people's
sexual, contraceptive and reproductive decisions and Health problems of the aged
behaviour
Modifying, extending and evaluating services specially
(1) PROBLEMS DUE TO THE AGEING PROCESS
designed to meet young people's needs. No one knows when old age begins. The
"biological age"
Mobilizing the energy, creativity and idealism of young of a person is not identical with his "chronological age". It is
people in promoting heal and developing said that nobody grows old merely by living a certain number
of years. Years wrinkle the skin, but worry, doubt, tear,
appropriate activities in their communities.
anxiety and self-distrust wrinkle the soul. While ageing merely
Facilitating action to extend education opportunities
for girls. stands for growing old, senescence is an expression used for
the deterioration in the vitality or the lowering of the
PREVENTIVE MEDICINE AND GERIATRICs biological efficiency that accompanies ageing. With the
passage of time, certain changes take place in an organism.
Ageing is a natural process. In th words of Seneca; "Old These changes are, for the most part deleterious and
is an incurable disease", but more recently, Sir James eventually lead to the death of the organism. Our knowledge
erling Ross commented "You do not heal old age. You about the ageing process is incomplete. We do not know
btect it; you promote it; you extend it" (140). These are in much about the disabilities incident to the ageing process.
ct the basic principles of preventive medicine. Old age However the following are some of the disabilities considered
Ould be regarded as a normal, inevitable biological as incident to it; (a) senile cataract, (b) glaucoma, (c) nerve
enomenon. The study of the physical and psychological deafness, (d) osteoporosis affecting mobility, (e) emphysema,
nanges which
are incident old age is called gerontology. () failure of special senses, (g) changes in mental outlook.
ne
aged is called clinical gerontology or
care of the This list is not exhaustive; we need to know a lot more about
eriatrics.Another aspect of gerontology is social the disabilities incident to the ageing process.
erontology which was born on the one hand out of the
stincts of humanitarian and social attitudes and on the (2) PROBLEMS ASSOCIATED WITH LONG-TERM
her out of the problems set by the increasing number of ILLNESS
0 people. Experimental gerontology is concerned with Certain chronic diseases are more frequent among the
esearch into the basic biological problems of ageing, into its older people than in the younger people. These are
stology, biochemistry, pathology and psychology. The (a) DEGENERATIVE DISEASES OF HEART AND BLOOD
s of studies range from studies of populations through VESSELS: Of particular importance after the age of 40, are
Viduals, organs, systems, tissues and cells, down to the the degenerative diseases of the heart and blood vessels.
ecular level. GERIATRIC GYNAECOLOGY: With the The inner walls of arteries break down, and a lipoid material
ening span of life a new chapter in gynaecology is deposited. This in time is replaced by calcium which leads
iC for gynaecology is fast opening up. More patients are
- to narrowing of blood vessels or atherosclerosis. This leads
Sng repair of prolapse of varying degrees, non- to diminished blood supply, thrombus formation, rupture of
S vaginitis, ovarian tumours, psychic aberrations and blood vessels and high blood pressure. No single factor
has
ho problems. There is ample scope for research into been identified as the cause of atherosclerosis. Diet,
degenerative and
treatment ther diseases of old age; their
in hospital and general practice; and finally into
heredity, overweight, nervous and emotional strain
have all
preventive been implicated. Cardiovascular diseases are the major
geriatrics and the epidemiology of conditions causes of death in the developed countries. A
lecting the aged. body weight and modification of the habits of
reduction of
life are
Size of needed to decrease the strain on heart and blood
the problem vessels. By
these, it is possible to lead a longer and more
Discoveries
social (b) CANCER: The danger of cancer useful life.
conditio in medical science and improved looms
ife. In the developed countries, cancer is alarge past middle
Span ofauring past few decades have increased the life
expectation of life at birth in developed death. The incidence of cancer rises rapidlyleading cause of
nthe ies is overhe80 years.The age structure of the population
Countripe after the age of
40. Cancer of the prostate is common after
deoped countries has so evolved that the numbers of (c) ACCIDENTS the age of 65.
Accidents are a health
problem in the
 area
s
NUTRITON AND HEALTH
704 is most effective in reducinggums ucose
blood glucrs nitrients
to other and cholet RtarErns
Examples levels as compared
Gl range amOunts
Classification
(except Fibre have no metabolic effects. Hou owever ntial no
Low GI 55 or less most fruit and vegetables sweet fibre can decrease the absorption of valuable Ca
tittrients
Potatoes, watermelon and foods, as to whether icron mall
Corn), whole grains, pasta There is conflicting evidence like re tends itentazs them
some vitamins and minerals calcium, t
Medium G1 56-69
beans, lentils
sucrose, basmati rice, brown rice and zinc, and reduce their
bio-availabilitu esim
well-balanced diet obtain enough toughage ple
wh
sthestE
iher foc
tme vit
some white fibnsiderin
High GI 70 or corn flakes, baked potato, qualitative and quantitative decrease in content
stances arg
jasmine), white
rice varieties (e.g.
Vitamirns
more foods. over the past many decades, an increase in dietaro
bread, candy bar and syruPy
particularly from cereals emerge as a recommend.y Ina ft
over a day can redeon,
Dasa
g
G-Glycaemic index in excess of 60 of tibre Dutrio
DIETARY FIBRE absorption and cause bowel irritation (9). A dail intate arttcula
ritanun
kcali
about 30 grams of dietary tibre in 2000
per For
remnants of the edible different incable p
By definition "Dietary fibre is the estimates of dietary fibre intake mesegmerts seases.
that are resistant
part of plants and analogous carbohydrates
human small intestine reported from western India are rural-39 gram f ay for TanEnance
to digestion and absorption in the
in the human large
men and 30 g/day for women; tribal 19 g/dau
41 gdau fenmen an Ceter
with complete or partial fermentation 15 g/day for women; industrial
-

oligosaccharides, sOmewnas
beet
intestine includes polysaccharides,
It 31 g/day for women; high income
group 31 glda t and
Dietary fibre exhibits group-43men
lignin and associated plant substances.bulking and softening; and 21 g/day for women; middle income
(faecal
one or more of either laxation regularity), men and 22 g/day for
women; and low incormay for
blood cholesterol for women (11) Tu
increased frequency; and or glucose attenuation. Organic 24 g/day for men and Z0 g/day upon the nature natur
ne actual Vitama
attenuation, and or blood (sorbitol) are also considered fibre intake depends of cereals
quantity of used Theals pa
acids (butyric acid) and polyols pulses, whole grain, vegetablesare as and millets
and a
contain any fibre. COnverte
as part of fibre. Animal foods do not shown in Tablo
fibre content of common foods nternatic
TABLE 4
Type and sources pre
by its source, e.g. in selected Indian foed
fibre fractions and
Different dietary
Dietary fibres have been characterized solubility in water soluble
-
eSpec
cereal, vegetable and fruits or its Food Name Dietary Fibre (g100 g for
characters of solubility are Food Group
(partly or fully) or insoluble. Both Digestibility of fibre is Total Insoluble Soluble
essential for health promotion. structural properties of the 11.49 9.14 2.34
the
determined by physiochemical and used. When exposed to Cereals and Bajra 10.22 8.49 1.73
itam
component and the process millets Jowar orU
dietary conditions in large intestine, Ragi 11.18 9.51 1.61
longer duration of degradative substance for fermentation Rice, raw, milled 2.81 1.99 082
more fibre is digested. It forms the this mechanism that part Wheat, whole 11.23 9.63 1.60
by intestinal microbes. It is through 25.22 22.70
starch is rendered available.
Apart Grain Bengal gram, whole 2.52
of energy from resistant during digestion, at legumesS Green gram, whole 17.04 14.59 244
from the energy yielding reactions 16.57 13.86 2.70
fibres promotes Rajmah, red
the action of enzymes on dietary brownn 21.55 16.56 5.00
different pH, It also changes the pattern of Soya bean,
3.21 1.20
interaction between nutrients. and thus the metabolic Green leafy Amaranth
leaves, 4.41
microbes colonizing the colon green
over the time. Vegetarians may vegetables 5.60 4.32 129
products of such fermentation pattern than that of the non- Colocasia leaves,
green
have different digestion derive different health benefits. This Drumstick leaves 8.21 6.12 2.10

vegetarians and thus 9.34 1.36

characterized by helpful microbes Tamarind leaves, 10.70
knowledge of probiotics
promoting the colonization of tender
and prebiotics (substrates up new areas for research (9). 2.84 1.14
Brinjal 3.98 1.23
probiotic strains) has opened insoluble
Other
vegetables Drumstick 6.83 5.60
1.28
covered all that was 4.08 2.80
Original estimates of fibre It was Ladies finger
acid and alkali conditions. 1.43 1.16
in dilute big 2.59
boiling water or structural Apple, 2.88 0.59
in
fibre', which may include all Fruits
apple 3.46 1.14
reported as crude haemicellulose. It is related to
Pine
.60 8.46
fibre, cellulose, lignin and Sapota 137
of holding water and 4.18 2.81
has the property and Carrot, orange 1.13 0.58
digestibility and It adds to the bulk of the Roots brown skin 1.71 0.76
diet. Potato,
swelling properties of the transit time of the food in the tubers
Tapioca 4.61 3.85
increases 26.55 4.60
food, favours satiety,substrate in the large intestine for release Condiments Chillies, red 31.15
27.63
gut and is an active components like organic acids
and
spices Fenugreek seeds 47.55
30.61 2.54
important functional carbohydrates, such as and
Pepper, black 33.16
of 2.52
nutraceuticals. Mostly complex haemicellulose, pectin and a Almond
13.06 10.55
13.57
3.59
Nuts and
polysaccharides i.e. cellulose, the fibre. oil seedsS Gingelly seeds, black 17.1
10.63
3.41
mucilages form 14.10
variety of gums, associated with reduced Mustard seeds
3.11 2.76
0.35
to be
Dietary fibre is known disease. The mechanism of its Mushrooms Button mushroom, 0.99
heart fresh
incidence of coronary binding to bile salts and preventing 3.02 2.03
Shiitake mushroom,
to its
action is attributed thus reducing cholesterol level in fresh 39.12 35.64 3.48

its reabsorption
and pectin, when Oyster mushroomn,
particularly the gum and post-prandial
circulation. The fibre, dried
with a diet, are reported to reduce shown that gum
ingested Recent studies have Source: (11)
glucose level in blood. seeds, which contains 40 per cent
gum,
present infenugreek
 206 NUTRITION AND HEALTH
Assessment of vitamin A deficies
Ooking smooth and shiny, it appears muddy and wrinkled. it
nas been well described as "emerging like sand banks at The formulation of an effective inter
receding tide" when the child ceases to cry (Zl). or prevention of vitamin A deficiencu ention ogTamimg
degine
(c) Bitot's characterization of the problem. This is
spots surveys employing both clinical and bioch
by
populat
5itot s spots are triangular, pearly-white or yellowish, These surveys (prevalence surveys) are donical0- iteta
amy spots on the bulbar conjunctiva on either side of the children (6 months to 6 years) who areon Pre
cornca. They are frequently bilateral. Bitot's spots in young The criteria recommended by WHO (18 are specia
children usually indicate vitamin A deficiency. In older Table 6. The presence of any one of the s giv t
ndividuals, these spots are often inactive sequelae of earner be considered as evidence of a xerophthaleria
halmia sh
shoul
disease. the community. problem
i
(d) Corneal xerosis TABLE 66

his stage is particularly serious. The cornea appears

I Prevalence criteria tor determining
xerophthalmia problem the
aul, dry and non-wettable and eventually opaque.
It does
not have a moist appearance. In more severe deticiency
there may be corneal ulceration. The ulcer may heal leaving Criteria Prevalence
in population
a corneal scar which can affect at risk (6 months
vision. to 6year
(e) Keratomalacia Nightblindness more than I per
cent
Bitot's spots morethan 0.5 per
Keratomalacia or liquefaction of the cornea is a grave Corneal xerosis/corneal more than 0.01 cent
per cent
medical emergency. The cornea (a part or the whole) may ulceration/keratomalacia
become soft and may burst open. The process is a rapid Corneal scar more than 0.05 per
one. It the eye collapses, vision is lost. Serum retinol (less more than5 per
cent
cent
than 10 mcg/dl)
EXTRA-OCULAR MANIFESTATIONS
Source: (18)
These comprise follicular hyperkeratosis, anorexia and
growth retardation which have long been recognized. Ihey
are non-specific and difficult to quantify. Recent studies Recommended allowances
seem to indicate that even mild vitamin A deficiency causes The present committee revised the carotene conversion
an increase in morbidity and mortality due to respiratory ratio to account for tisSue conversion, and general
and intestinal infection (22). Deficiency of vitamin A has conversion factor of 6:1 is recommended tor all carotenoids
recently been linked to child mortality (23). except B-cryptoxanthine and a-carotene where a CF of 121
is recommended.lhe detailed recommendations are as given
Treatment in Table 28.
Vitamin A deficiency should be treated urgently. Nearly
all of the early stages of xerophthalmia can be reversed by
Toxicity
administration of a massive dose (200,000 ITU or 110 mg of An excess intake of retinol causes nausea, vomiting,
retinol palmitate) orally on two successive days (24). All anorexia and sleep disorders followed by skin desquamation
children with corneal ulcers should receive vitamin A and then an enlarged liver and papillar oedema. High
whether or not a deficiency is suspected. intakes of carotene may colour plasma and skin, but do not
appear to be dangerous (19, 27). The teratogenic effects of
Prevention massive doses of vitamin A is the most recent tocus o
Prevention interest (28).
and/or control takes two forms
(a) improvement of people's diet so as to ensure a regular
and adequate intake of foods rich in vitamin A, and (b) VITAMIN D
reducing the frequency and severity of contributory factors, The nutritionally important forms of Vitamin D in mat
e.g. PEM, respiratory tract intections, diarrhoea and are Calciferol (Vitamin D,) and Cholecalciferol (Vitamin
measles. Both are long term measures involving intensive Calciferol may be derived by irradiation of the plant ste
nutrition education of the public and community
ergosterol. Cholecalciferol is the naturaly OCEh
participation. preformed) vitamin D which is found in animal fats an ha
Since vitamin A can be stored in the body for 6 to 9 liver oils. It is also derived from exposure to UV raysmin
months and liberated slowly, a short term, simple technology Sunlight which convert the cholesterol in the skin to Vtau
had been evolved by the National Institute of Nutrition at D. Vitamin D is stored largely in the fat depots.
Hyderabad (India) for community based intervention
against nutritional blindness, which has subsequently been Vitamin D: Kidney hormone
in our
adopted by other countries (25)The strategy is to Major advances have been made in recent
s

administer a single massive dose of 200,000 10 of vitamin A understanding of the metabolism ot Vitam itseli,
in oil (retinol palmitate) orally every 6 months to preschool
children (1 year to 6 years), and half that dose (100,000 IU) 29t is now known that vitamin D,
metabolically inactive unless it undergoes
De
o
enous
d., 2
to children between 6 months and one year of age (24). In transformation into several active metabol kidne
this way, the child would be, as it were "immunized" In the
HCC; 1:25 DHCC) first in the liver and later in.protin
against xerophthalmia. The protection afforded by These metabolites are bound to specinc
six-monthly dosing seems very adequate as measured by uaintestine
and are carried to the target tissues- bone aarded as
clinical signs of deficiency (26). has been proposed that vitamin D should be Eg
 707
nne (30)
hormone (30) because it does not meet the classlc
Ainey vitamin,
vito that is, a substance whlclh must be oth rickets and osteomalacia were frequently reporte
heliiluon of a means cause ol a lack of capacity ndl, although they do not appear to be a problem o
dietary
Mainhdy
by
to synthesize it, ln fact, vitamin D, is not
in pubic hcalh importance, In the world as a whole, thieir
haman bocl prevalence has declined as a 1esult of changes in s0c
the requircnent at all in conditions ol adequatle sunlight. Customs (e.g., purdah systern), and the expansion of mother
kearyy
ethesized in the body in aclequate amounts by and child healih services lending to better care and feeding
sinple
sure
an cxpoSUre to sunlsunlight even tor minutes per day. of inlants and children (3). In the developing Counrle
oday, rickets as a menace to child health is oyershadoved
Functions by the prevalence of protein-energy-malnutrition.
The unctions of vitamin D are as summarized in Table 7.
Prevention
TABLE 7 Prevention measures include (a) educating parents to
Functions of vitamin D and its metabolites expose their children regularly to sunshine; (b) periodi
ntestine Promotes intestinal absorplion of calclum and dosing (prophylaxis) of young children with vitamin D; and
phosphorus (c) vitamin D fortification of foods, especially milk. Sorne
Stimulates normal mineralization, enhances industrialized countries still carry out the last measure
Bona
bone reabsorption, aftects collagen maturation.| Periodic dosing and education appear to be the nost
Increases tubular reabsorption of phosphate, praciical approaches in developing countries.
idney Variable effect on reabsorption of calcium
Fraser (32) urges caution concerning oral
Permits normal growth.
Dther
supplementation, because orally administered vitamin D
Source:57 appears to bypass the protective mechanism that prevent
excessive 25(OH)D, formation. The margin of safety with
Sources oral vitamin D between the nutrient requirement and toxic
Vilamin D is unique because it is derived both from intake is narrow.
sunlight
and foods. (a) Sunlight : Vitamin D is synthesized Vitamin D is stored in the body in fatty tissues and in the
by the body by the action otf Uv rays of sunlight on liver. An excessive intake is harmful and may result in
-dehydrocholesterol, which is stored in large abundance in anorexia, nausea, vomiting, thirst, and drowsiness.. The
the skin. Exposure to UV rays is critical; these can be filtered patient may lapse into coma, while cardiac arrhythmias and
offby air pollution. Dark-skinned races such as Negros, also renal failure may occur. The effects are due to
suffer from this disadvantage because black skin can filter off hypercalcaemia induced by increased intestinal absorption
upto 95 per cent of UV rays. (b) Foods: Vitamin D occurs and mobilization of calcium from bone. Recent literature
only in foods of animal origin. Liver, egg yolk, butter and contains warning against the administration of amounts of
cheese, and some species of fish contain useful amounts. vitamin D that greatly exceed accepted requirement levels.
Fish liver oils, although not
considered to be a food, are the This warning applies to pregnant women also since
richest source of vitamin D. Human milk has been shown to manifestations of hypercalcaemia may develop in utero (4).
contain considerable amounts of water-soluble vitamin
Dsulphate (31). Other sources of vitamin D are foods Daily requirements
artificially fortified with
vitamin D, such as milk, margarine, The expert committee of ICMR emphasizes importance of
vanaspati and infant foods. Dietary sources of vitamin D are outdoor physical activities as a means of achieving adequate
as given in Table 8. vitamin D status in a tropical country like India. However,
under minimal exposure to sunlight, particularly in certain
TABLE 8 urban groups, like 1-2 year old children, a specific
Dietary sources of vitamin D recommendation of a daily supplement of 600 IU is
100Og
suggested (11).
Hg/per 100g Hg/per
Butter
0.5-1.5 30-100
VITAMINE
Shark liver oil (Tocopherol)
Eggs
1.25-1.5 Cod liver oil 200-750
Milk, whole
0.1 Halibut liver oil 500-10,000 Vitamin E is the generic name for a group of closely related
fat
sh 5-30 and naturally occurring fat soluble compounds, the
Deliciency tocopherols. Of these alpha-tocopherol is biologically the
most potent. Vitamin E is widely distributed in foods. By far
leads to rickets, which the richest sources are vegetable oils, cotton-seed, sunflower
ickets: Vitamin D deficiency
seed, egg yolk and butter. Foods rich in polyunsaturated fatty
lly observed in young children between the age of six acids are also rich in vitamin E. The usual plasma level of
C and two years. There is reduced calcification ot
vitamin E in adults is between 0.8 and 1.4 mg per 100 ml (31).
al 0Ones. The disease is characterized by growth While there is no doubt that man requires tocopherol
bone deformity, muscular hypotonia, tetany and in his
diet, there is no clear indication of dietary deficiency. The
lsions due
ncentration
to hypocalcaemia. There is an elevated of vitamin E at the molecular level is little understood.
role
of alkaline phosphate in the serum. The bony current estimate of vitamin E requirement is about 0.8 mg/gThe
Chest
Hancude curved legs, deformed pelvis, pigeon essential fatty acids. Ihis roughly works out to of
Ihe
mil5on's sulcus, rickety rosary, kyphoscoliosis, etc. tocopherol per day depending on the edible oil 7.5-10 mg
ilestones of developme used (11).
deelaue such as walking and teethingD Recently the cytotoxic effect of vitamin E
ayed.
aeliciency (2) nalacia In adults, vitamin on human
may result in osteomalacia occurs mainly lumphocytes in vitro at high concentrations
WOmody nen, especially
which reported. This being so, caution should be has been
tequirements during pregnancy and lactation when exercised against
inents Ot
of vitamin D are increased. the mega-dose consumption of vitamin E in clinical practice.

T
 708 NLPRION AND 1AJF
VITAMIN K
Thiamine losses
Thiamine is readily lost from rice
Vitamin Koccurs in at least two major formsvitamin K
green
milling. Being a water-sof e during
amin, thestven
atat
and vitamin R Vitamin K, is found mainly in fresh place during washing and cooking furthe
vegetables particularly dark green ones, and in some fruits for advising people to eschew highof rice.
Thi
polished
Cow's nmilk is a richer source (60 meg/L) of vitamin K than parboiled or under-milled rice
(see
human milk (15 meg/L). Vitamin K, is synthesized by the thiamine in fruits and vegetables page
intestinal bacteria, which usually provides an adequate prolonged storage (55) hiamine isi alerally Ti6
Supply in man. Long-term administration of antibiotic doses and in cereals coOked with baking sor etr NCreals
for more than a week may temporarily suppress the normal absence of beriberi is determined by
intestinal flora, (a source of vitamin K,) and may cause a cultural practices concerning the the local
deficiency of vitamin K. Vitamin K is stored in the liver processing o
rice and ofher foodstuffs. a
The role of vitamin K is to stimulate the production and
or the release of certain coagulation factors. In vitamin K Deficiency
deticiency. the prothrombin content of blood is markedly The two principal deticiency diseases
decreased and the blood clotting time is considerably Wernick's encephalopathy. Beriberi
prolonged. mauae berk
forms (a) the dry form characterízed
peripheral neuritis); (6) the wet form hurrve iny
The vitamin K requirement
inth
of man is met by a
combination of dietary intake and microbial synthesiS in tne involvement (cardiac beriberi); and (cl
ierized h
ut he daily requirement for man appears to be about
0.03 mg/kg for the adult. Newborn infants tend to
seen in infants befween 2 and 4 monthsantile
baby is usually breast-fed by a thíamine.eage.Theeriben
he

deficient in vitamin K due to minimal stores of prothrombin

be affe
rurCcE34
who commonly shows signs of periphers
at birth and lack of an established intestinal flora. Soon alter Wernick's encephalopathy (seen mehe
Deticienc
birth, all infants or those at increased risk should receive a is characterized by ophthalmoplegia,
often eropat
Single intramuscular dose of a vitamin K preparation
in alcshsc
polune mas
and mental deterioration. It occurs euritis. The
(0.1-0.2 mg of menadione sodium bisulphite or 0.5 mg of who fast. occasíona at deticiency
vitamin K,) by way of prophylaxis (33). mElnour7sh
A few short decades ago, frank cases stats
B GROUP OF VITAMINS be frequently seen in the coastal districts of hori of the
where people eat highly polished rice. of Andsed clinical sig
THIAMINE (B,) ICMR showed that such cases are Investigaade gcssttts
now wnen
Thiamine (vitamin B,) is a water-soluble vitamin. It is because of improved soci0-economicrarelt nIcountered the ven
have
essential for the utilization of carbohydrates. diversification in the diet consumed conditio
tions may
TErornoto
Thiamine now (36
Pyrophosphate (TPP), the coenzyme of cocarboxylase plays SUSCEptIO
a part in activating transketolase, an enzyme Prevention
direct oxidative pathway for glucose. In
involved in the aivays oc
thiamine deficiency, Beriberi can be eliminated by educating B-compleK
there is accumulation of pyruvic well-balanced, mixed diets containing peanle s. muliple
and lactic acids in the thiamine-tich
tissues and body fluids. (e.g., parboiled and undermil à
rice) and to Requirer
alcohol. Direct supplementation of high-risk stop
Sources qrOIne
lactating mothers) is another approach. Beriberi tonde There
equiremne
Thiamine occurs in all natural foods, although disappear as economic conditions improve ends t
amounts. Important sources are : whole grain cereals,in small become more varied (10). Ihe disease, as has andshown diets For turthe2
gram, yeast, pulses, oilseeds and nuts, wheat, is not completely vanquished been
especially groundnut. but the knowledae ant
Meat, fish, eggs, vegetables and fruits resources needed to bring about its disappearance
contain smaller
amounts. Milk is an important source of thiamine a
available (3). Niacin
provided the thiamine status of their mothers is for infants, of carbo
satisfactory.
The main source of thiamine in the diet of
Indian people is Recommended allowances norma
cereals (rice and wheat) which contribute from The body content of thiamine is placed at 30 mg. and if Stems.
cent of the total supply. The thiamine 60-85 per
content of selected more than this is given it is merely lost in the urine (19 B-compt
food stuff is given in Table 9. Patients on regular haemodialysis should routinely be given Typtoph=
macin is
TABLE 9 supplements of thiamine. Thiamine should also be given
metabolf
prophylactically to people with persistent vomiting or N-methy-
Dietary sources of thiamine prolonged gastric aspiration and those who go on long fasts.
Foods of For further details see Table 28.
Foods of animal Sourc
vegetable origin mg/100 g mg/100 g
origin Food
Wheat (whole) RIBOFLAVIN (B,)
0.45 Milk, cow's 0.05 meat
Rice, raw homepounded 0.21 Egg hen's 0.10 Riboflavin (Vitamin B,) is a member of the B-group SQurceo

Rice, milled 0.06 Mutton Vitamins. It has a fundamental role in cellular oxidation. t Con
0.18 plays an important role in maintaining the integrity or ryptop
Bengal gram dhal 0.48 Liver, sheep 0.36 cereals
Almonds
mucocutaneous structure. It is a co-factor in a number a
0.24 enzymes involved with energy metabolism. t 1S unavai
Singelly seeds 1.01 involved in antioxidant activity, being a co-tactor tor Defic
roundnut 0.90 enzymes like glutathione reductace and is requiredtot
metabolism of other vitamins like vitamin Bo, niacit Nia
urce: (34) vitamin K (9). Chara
 VITAMINS
709
OcCur
stomatitis usually oniy
addition glossitis
and
symmetrical and is found as
such
dementia. In bilaterally exposed to sunlight, changes
dernmatitis is body Mental
milk, eggs, liver, kidney and
ne those
surtaces of the legs, and neck. irritability and
facedepression,
Gources are On hands, lower
natural SOurces contain small amounts. Oack of the include
Is riC t ogetables. Meat and fish
milled) and pulses are relatively may also occur which
deficiency disease
mEen ledhether whole
or which they are widespread
because of the bulk
ulk in delirium.
formidable and subsisting mainly
on maize
rces but riboflavin to Indian a population world. It is still
contribute much of the content of pulseS Oncemalnourished
parts of the Africa
pood they
consurormination increases the
ribotlavin
common foods among
has declined in all Asia and Southern While
ns some pellagra Western (38).
ribolavin content of alets, parts of little else maize-eating
etsals.
cereals. The 10. prevalent in some subsist on maize and of the or
and
givenin
lable
TABLE 10 wnere peoplehistorically a disease the Telangana area
is India in population eating
is ot riboflavin
pellagra reported in
Population, it was some segments(Sorghum of the vulgare), these
Dietary sources
foods of animal
vegetable Pradesh in
Foods of mg/100 g Andhra jowar
mg/100 g origin another cereal - that is little of milk or other
have shown that
Foods of
0.10-0.16 consuming very and others (39)
leucine is the
origin people by Gopalan of
sets
animal
1.70 Whole cereals
0.03-0.08 origin. Studies caused by an excesseaters. Excess of
Milled cereals
imbalance maize tryptopnan
Liver,sheep amino- acid jowar and
cow's
0.19 0.21-0.32
cause of pellagra in both in the conversion of
Milk Pulses to interfere
leucine appears
0.40 0.15-0.30
vegetables
Egg.hen 0.14 eafy
nle Meat
to niacin.
Ihe mixed diet
bource (34)
Prevention preventable disease. A good regarded as an
Pellagra is a is
universally Avoidance of
Deticiency with riboflavin and/or meat
containing milk prevention and treatment.is an important
common lesion associated occurs frequently in of sorghum
essential part
neurtis
The most Given
tz angular stomatitis, which is used as an index dependence on maize or disease of poverty.
deficiency is
its prevalence (3). Other total Pellagra is a for economic,
malnourished children and groups of children cheilosis, preventive measure. and opportunities every reason to
berberi state of nutrition of specific) include modern
knowledge development, there is
Andhta a
sed of the
clinical signs
suggestive (but not etc. Hypo-riboflavinosis, agricultural and social could be eliminated (3).
Prae nasolabial dyssebacia, individual, but it disease
stigations alossitis,
severe, seldom
incapacitates the
as impaired hope that this
byte
even when such
functional effects perhaps increased
dly encourtie
may have subtle Requirement per day of
condilions wound healing and deficiency almost daily allowance is 12 mg
a neuromotor to cataract (37). Riboflavin
function, recommended details see Table 28.
of other The
(11). For further
susceptibility
association with deticiencies part of energy intake
always occurs
in it is usually a
as pyridoxine; PYRIDOXINE (B)
B-complex vitamins such syndrome.
multiple deficiency Pyridoxine,
g people to a a
exists in three forms role in
amine-rich taxs
Requirement riboflavin. Daily (vitamin B)
Pyridoxine pyridoxamine. It plays an important
stores of carbohydrate. It is
and to stop
no real body energy intake (11). pyridoxal and amino-acids, fats and
There are
per 1000 kcal of metabolism of meat, egg yolk,
e.g., milk, liver,
isk groups teg
requirement is 1.96 mg the
tends
see Table 28. widely distributed
in foods, and vegetables.
cereals, legumes peripheral neuritis.
eriben
For further details
rOve and de grain
NIACIN (B,) fish, wholedeficiency is associated with utilization of
has been shosn
knowledge and essential for the metabolism Pyridoxine
deficiency impairs the optimalis a recognized
acid (B,) is essential for the Riboflavin antituberculosis drug with a
sappearancear Niacin or nicotinic protein. It is also nervous pyridoxine. INH, an INH are provided
carbohydrate, fat and intestinal and patients receiving
of
the skin, vitamins of the antagonist, andpyridoxine (10 mg/day).
normal functioning of from the other amino acid, supplement of
differs directly with protein
Systems. This vitamin essential of adults vary
5-complex group in
that an characteristic of The requirements during pregnancy and
mgan precursor. Another is may need 2 mg/day; contain
30
at urine(09 tryptophan serves as its
excreted in
such,
urine as derivatives
but intake. Adults
mg/day. Balanced diets usually details
is that it is not
2.5 further
the
ge hlacin methylated lactation, deficiency is rare. For
Utnely be metabolized to at least 2
major
pyridones. pyridoxine, therefore
gu N-methyl-nicotinamide and N-methyl
d
also be
voming
see Table 28.
nt long Sources kidney PANTOTHENIC ACID (B)
goon and/or tryptophan are liver, a poor
Tich in niacin groundnut. Milk is which relation between
Oas poultry, fish, legumes and tryptophan long
is a standing evidence for a function. Work
cat, There adrenal cortical
of niacin but its
proteins are rich in (about 60 mg of pantothenic acid and pantothenic acid in the
B-go Ce niacin
converted in the body intoin 1 mg of niacin). In formn
many specific role for
indicates a morecorticosteroids (7). Human blood normally
the to result
of
oxidation.
Iophan is required occurs in "bound biosynthesis of
mg of pantothenic acid
per 100 ml, mostly
lar integrya In
especially maize, niacin
unavailable to the consumer.
contains 18 to 35
cells as coenzyme A. The
daily requirement is
the present in the
All foods contribute
to dietary intake.
20 set at 5 mg (31).
ie Deficiency disease is excreted daily in urine.
sm. tor
pellagra. The About 3 mg are
torte
COlactor
Niacin deficiency results in dermatitis and
Characterized by three D's diarrhoea,
equired
 NOTRITION AND HILALTHH
710 Bie
FOLATE cheese. Vitamin B, is not found in foods of yond
It is also synthesized by bacteria in colon.
Uni e I00g
likefolico
The recommended name is folate, alternative name
is vitamin B,, is relatively heat stable. Liver is the mg
folacin and the usual pharmaceutical preparation is folic site of vitamin B2 About 2 mg are stored stor
acid (19). another 2 mg elsewhere in the body. These in liver,
Folic acid occurs in food in two forms free folates and
: sufficient to tide over any deficiency for one ttore
Because of these reserves, deficiency of vitamin Dyea
bound folates. The total folates represent both the groups. In to be rare. B,appea Amla
man, free folate is rapidly absorbed, primarily from the Crtava
proximal part of small intestine. The availability of bound Deficiency
folate is uncertain. Folic acid plays a role in the synthesis of Crange
the nucleic acids (which constitute the chromosomes). It is Vitamin B, deficiency is associated with mega Tomato pulses
also needed for the normal development of blood cells in the anaemia (pernicious anaemia), demyelinating nsoblasti
lesions in the spinal cord and inferti urologica Germinated
marrow. (in animal s gram
which is rarely seen in India, While clinical Bengal
Sources B, is not manifested, sub-clinical deficiencu s Source:(3
exist in India. Reports indicate that there exist orted to
The name comes from the latin folia (= leaf) but foods 30 per cent deficiency in adults and children in me ore than
such as liver, meat, dairy products, eggs, milk, fruits and peficiency
It is not surprising that blood levels of vitarmin R ntry
cereals are as good dietary sources as leafy vegetables. since a large proportion of population Deticienc
Overcooking destroys much of folic acid and thus depends" lOu
food for nutrients (9) plant are
contributes to folate deficiency in man. Folate deficiency has
been reported in babies given milk foods subjected to heat Requirement
ufich
o ble
bruisinganaer
sterilization. Intake values recommended by ICMR (2020 healing,
defi
are important
Deficiency below (11). Detailed requirements are as shown in Tahle mportance3
le28.
Folate deticiency may occur simply from a poor diet. It is Per day Requireme
Commonly found in pregnancy and lactation (40) where a) Normal adults 2.2 mcg
requirements are increased. It results in megaloblastic estim
b) Pregnancy +0.25 mcg The
adu
anaemia, glossitis, cheilosis and gastrointestinal for abbo
c) Lactation +1.0 mcg3
disturbances such as diarrhoea, distension and flatulence. Contains
1CMR
Severe folate deficiency may cause infertility or even d) Infants & children 2.2 mcg
sterility. There is also evidence that the administration of oythe
folic acid antagonists (e.g., alcohol, pyrimethamine, and VITAMIN C
cotrimoxazole) in early pregnancy may produce abortions or
congenital malformations. Vitamin C (ascorbic acid) is a water-soluble vitamin. It More tha
is
The laboratory diagnosis of folate deficiency is based on the most sensitive of all vitamins to heat. Man, monkey body,whic
and
measurement of serum and red cell folate concentrations, guinea pig are perhaps the only species known to vital
body
usually by microbiological assay (41). reguire
vitamin C in their diet. groups
phosphoru
Requirement Functions TRACE
6)
Body stores of folate are not large, about 5-10 mg, and Vitamin C is a potent antioxidant and has an important body in q
therefore, folate deficiency can develop quickly. Folic acid role to play in tissue oxidation. It is needed tor the formation ron,
requirements are greatest in conditions where there is rapid of collagen, which accounts for 25 per cent of total body mangane
cell multiplication, such as during growth in young children protein (7). Collagen provides a supporting matrix for the vanadiur
and during pregnancy (41). Folic acid supplementation blood vessels and connective tissue, and for bones and the last
f

during pregnancy has been found to increase the birth cartilage. That explains why in vitamin C deficiency this NO KNC
weight of infants and decrease the incidence of low birth
support fails, with the result that local haemorrhages occur barium,
weight babies. Intake values recommended by ICMR (2020)
are given in Table 28. and the bones fracture easily. Vitamin C, by reducing feric Only
iron to ferrous iron, facilitates the absorption of iron from potassik

VITAMIN B,, vegetable foods. It inhibits nitrosamine formation by the with cle
intestinal mucosa. Other claims such as prevention of i
the
Vitamin B, is complex organo-metallic compound with a common cold and protection against infections are not their

cobalt atom. The preparation which is therapeutically used substantiated. dietar

is cyanocobalmin, which is relatively cheap. Vitamin B2 Such

cooperates with folate in the synthesis of DNA, so deficiency Sources becau

of either leads to megaloblastosis. Vitamin B,, has a separate The main dietary sources of vitamin C are fresh fruits and Besic

biochemical role, unrelated to folate, in synthesis of fatty green leafy vegetables. Traces of vitamin C occur in fresh prop

acids in myelin (19). The physiological mechanism for its meat and fish but scarcely in cereals. Germinating pulses ele
absorption requires intrinsic factor from the stomach, and contain good amounts. Roots and tubers contain smal nave

the complex is absorbed only at a special site in the terminal amounts. Amla or the Indian gooseberry is one of the richest veg

ileum sources of vitamin C both in the fresh as well as in the dry ee

condition. Guavas are another cheap but rich source ot this
in
Sources vitamin. The dietary sources of vitamin C are as given
Good sources are liver, kidney, meat, fish, eggs, milk and Table 11.
wwwwww
MINERA
711

CALCIUM
TABLE 11 body
sources of vitami C mineral element of the an adut
of
Dietary alcium is a majorcent of the body weight 1200 g ot
On8ttues 1.5-2 per about
mg/100 g body contains bones. he
mg100 g
Vegetable
an
cacium of
An average adult cent is found in the
which over 98 per
calcium in the blood
is usually
about 10 mg/al
calcium. There
1h
rount of about 30 g of blood
The developing foetus requires in the
the calciummaintained o
Cabbage 124
600 equilibrium between
Amla 212 Amaranth 99 s dynamic equilibrium is
skeleton; this parathyroid hormone, and
Caulltlower 56 and that in the
uava 63 D,
ne nteraction of vitamin
30 Spinach 28
Lime probably calcitonin,
Oange Brinjal 12
27
Potatoes 17 Functions functions
has many vital
Tomato
or
calcium in the plasmaand teeth, coagulation
pulses y 15
Oerminated Raddish
gram 16 nized formation of bones action, mk
cardiac messages
Bengal nciuding of muscles, that
Dlood, contraction electrical and chemical biochemical
(84) Pproduction, relay of the
Source membrane to cells
cell's surface keeping the membranes of
Deficiency of arive at awithin the cell, hormones. it
C results in scurvy, the signs machinery enzymes and to
Deficieneyof vitamin subcutaneous metabolism of transformation of light 1on
swollen and bleeding
gums, intact and in the
or joints, delayed wound crucial role in the In short, the calcium
whlch are
bleeding into the skin
also plays a in the retina. muscle
or Scurvy which was once an electrical impulses ranging from
bruising
and akness. longer a disease of world life processes
healing.
anaemia is no Controls many
eficiency isease
important defi contraction to cell division.
importance (3)
Sources sources. By far
Requirement readily available from many products, (e.g.,
mg per Calcium is milk
tor vitamin C is 40 sources are milk and milk), eggs and fish.
estimated requlirement saturated the best natural
The when fully
The normal body intakes recommended skimmed milk and butter 1200 mg of calcium,
and
for adults cheese, curd, provides about milk as
dau
rontains about 5 g of
vitamin C. Daily A litre of cow's
milk Calcium occurs in by the
Table 28. 300 mg. assimilated
bythe ICMR
(11) are as given in human milk about which is readily leaty
calcium caseinogenate dietary sources are green in the
MINERALS body. The cheapest limiting factor
millets. The
vegetables, cereals and calcium from green leaty vegetables
the human with
50 chemical elements are found inregulation of complete absorption of is the presence of oxalic acid calcium
than repair and amaranth)
(e.g, spinach, forms an insoluble compound,
n. lt is More
required for growth,divided into three major Most
and body, which are
1These can be calcium, which calcium of calcium.
with the absorption and the millet
vital body functions.
equire
MAJOR MINERALS: These include magnesium; Oxalate which
interferes
providers of calcium,
groups:(a) deficient in
Sodium, potassium and required by the cereals are generousrich in calcium. Rice is very cereals is
phosphorus,
ELEMENTS: These are elements per day, e.g. "ragi" is particularlybioavailability of calcium from an
(6)TRACE
less than a few
milligrams calcium (43). The presence of phytic acid which forms An
body in quantities of
copper cobalt, chromium, poor because of the calcium phytate.
ortant
iron, iodine, fluorine,
zinc, silicon and with calcium, may
mation selenium, nickel, tin, insoluble compound calcium is drinking water which
molybdenum, in Sitaphal)
manganese, added to the list additional source of
mg/day. Some fruits
(e.g.
| body
Many more have been CONTAMINANTS WITH
for the
vanadium (41),
TRACE mercury, provide up to 200 of calcium.
years; and (c) amounts
and the last few
KNOWN FUNCTION These include lead, contain good
y this
NO
barium, boron, and aluminium. phosphorus, Absorption calcium is
OCcur
elements (e.g., calcium,are associated about 20-30 per cent of dietaryenhanced by
fernic Only a few mineral Overall, Absorption of calcium is
fluorine, iodine)
g

poassium, sodium, iron, For none normally absorbed. presence of phytates,

n from
recognizable clinical situations in man. for and decreased by the Calcium absorption is
certainty vitamin D
know with any
WIn clearly
by he acids in the diet.
elements do we effects of oxalates and fatty extent by the body's needs.
tion
are no
er other less the clinical
metabolic roles, and muchbio-availability of minerals regulated to some
ietary insufficiency (42). The vegetarian diet
be low in a total phytic acid Deficiency deficiency has ever
as iron and zinc may
presence of substances such asinterfere with clear-cut disease due to calcium
conditions low intake
(44). It
Uls
and
R ,O the
large amounts of dietary
absorption. Man is not
fibre may
likely to suffer
from trace
Surveys
No
been observed,
even
established
under of
that if the intake
of vitamin D is
osteomalacia do not
tresh
el as he is omnivorous. among has been problems of rickets and
in long adequate, the other hand, no
are no greater man's
deficiencies as
nt calcium intake. On the
pulses
7nsimall nave
that mineral deficiencies
non-vegetarians. In fact,precisely arise even
with low man as a result of
Own have been observed in
of dietary calcium,
vegetarians than am deleterious effects
erichest
yet been used as of large amounts
dry elements has not not be prolonged intakes demonstrated.
the determineae
determined Trace elements should amounts can have benetits been
fthis neither have any
egivenn dietary
supplements, Since excessive
njurious effects.
 total
of m
deticiency are irritahit. eroues
attributed to
magnesium
ility, ekany
occasionally hypo-reflexia. equirements 25whereve
NUTRITIONAND
HEALTH hyper-reflexia and about 44
estimated to be
440 mg/day for adults (11). For ar may
OEp
pattrolgical
712 suggested are 28.
Requirement
been
calcium has than earlier details see Table Hich
ulcer);(
mg of IRON
A daily
intake of 1,000
1.5 times requirements are
higher
ic use
SWeal
a
is
adults which(11). The
physiological mothers. Intake nutrition, Th
importance in human iron, uhi adult dspreaa
for
recommendation expectant and nursing Table 28. of great g of of adaitional
are as given in Jron is
contains between 3-4 iOOut
children, (11) human body cent in the blood (Hb
in
higher recommended by 1CMR is present stora s the
values 60-70 per rest (1 to 1.5 g) as
ma ateASe
PHOSPHORUS circulating iron, and the 3.34 ofOn
and haemoglobin contains about
formation of bonesadult Each gram of ner
essential for the metabolisms. An Edse
Phosphorus isimportant part in all phosphorus as Functions
g of inchudi
plays an 400-700 and teeth. many functions in the body functiorng defics
teeth. It
body contains about occurs in bones deficiency Iron is necessary for brain development and tion, ron st
its
formation of haemoglobin,
human this
ofdistributed in foodstuffs; present in
phosphates, most phosphorus body temperature, muscle activity, and hree
widely is regulation of the
Phosphorus is part of with phytin and of iron directly affects
occurs. A large combination per cent. catecholamine metabolism. Lack number of T-cells and th
rarely occurs in
vegetable foods body only to the
extent of 40-60specifically it diminishes the
immune system;antibodies. Besides haemoglobin, iron is a ntetmedia
been
available to the have not
requirementsCommittees, other groups of production of cytochromes, catalase and are
Phosphorus FAO/WHO but
intake should be
at component of myoglobin, the essential for binding oxygen Sores
considered bysuggested that phosphorus groups, except in systems. ron is Tecogn
certain enzyme of iron is "oxygen
experts have calcium intakes in most
age cells. The central function 5
1:1.5 (9). to the blood
least equal to
ratio suggested is transport", and cell respiration.
infancy where the ageis
SODIUM sta
Sources non-haem hird
human body iron, haem-iron and
There are two forms of absorbed than non-haem iron.
TeCTeas
fluids. The adult
Sodium is found in all body occurs in many iron. Haem-iron
is better fish. Lueto
100 g of sodium ion. Sodium cooking in the form rich in haem-iron are liver, meat, poultry and
contains about Foods sources of readily available iron
The
added to food during through importat
only
foods, and is also lost from the body They are not
absorption of non-haem iron in whICO
chloride. Sodium is is passed out in urine is but they also promote the
sodium time (47). The iron content
of
of sweat; that which which is lost by sweating is same
urine and but that plant foods eaten at the species. Iron content of breast
regulated by the kidney chloride causes milk is low in all mammalian
Depletion of sodium chloride than ).2 mg/dl, and it is well utilized.
not controlled. requirement of sodium activity. milk averages less
iron are those of vegetable
Foods containing non-haem
muscular cramps. The physical
occupation and leaty vegetables, legumes,
nuts,
depends upon climate, 5 g per day. A strong relationship origin, e.g., cereals, green They are important
fruits.
Adult requirement is about dietary salt intake has been oilseeds, jaggery and dried of a large majority of Indian
and
between hypertension more than 10 g of salt per day is sources of iron in the diets
observed and intake of blood The bioavailability of
non-haem iron is poor owing
definitive tendency to raise people. phytates, oxalates, carbonates,
considered to have to the presence of with iron
pressure (9). phosphates and dietary which fibre which interfere absorption are
Other foods inhibit iron
POTASSIUM absorption. which is
eggs and tea (48). The ndian diet these
milk, large amounts of
human body contains about 250 g of predominantly vegetarian contains phosphates in egg yolk,
adult
inhibitors, e.g., phytates in bran,
is
The widely in foodstuffs, so there In some areas,
potassium. Potassium occurs Potassium is vasoactive, in tea and oxalates in vegetables. cookingin
deficiency. tannin from
little likelihood of its metabolic needs of the amounts of iron may be derived
increases blood flow and sustains signiticant
Potassium
by endothelial cells. iron vessels.
tissue. Potassium is released pressure, although the response is
supplements lower blood
slow. Much of the
information regarding potassium and Absorption
duodenum and upper small
to dietary sodium. High dietary Iron is mostly absorbed from The
blood pressure is in relation been implicated in the ferrous state, according to body needs.
sodium, low dietary potassium
have intestine in the tactors
evidenced by epidemiological influenced by a great many
aetiology of hypertension as rate of iron absorption is the presence of
inhibitors
reserves of the subjects,
clinical studies (9). like iron acid and
ratio in the diet is phosphates), and promoters (e.g., ascorbic disorders ot
potassium (e.g, absorption, and
The ideal desirable sodium: ascorbic acid-rich foods) of iron coeliac disease, tropica
1:1 (in mmol).
duodenum and jejunum (e.g., when there is an increasea
sprue). Iron absorption is
greater pregnancy. rO
MAGNESIUM example during
demand for iron, as for
present in all habitual Indian diets is less than 5 per cent,
of bones, and is absorption from
Magnesium is a constituent
contains about 25 g of the bioavailability being poor.
body cells. Human adult body found in the skeleton. It as plasma ferrifin The
and
magnesium of which about half is normal The absorbed iron is transported marrow and kidney.
for the
appears that magnesium is essential (45). Magnesium stored in liver, spleen, bone metabolism is conservati0n
metabolism of calcium and potassium characteristic feature of iron
cirrhosis of liver, liberated iron
deticiency may occur in chronic alcoholics,
When red cells are broken down, the
malnutrition and cells.
toxemias of pregnancy, protein-energy clinical features reutilized in the formation of new red
malabsoption syndrome (46). The principal
 ELEMENTS 715
OTHER TRACE

disease, pernicious anaemia, thalassaemia and Selenium in

ial infarction. Zinc denciency 1s common in children earlier to selenium
Little attention had been given
as
selenium deticiency
mdeveloping countries aue to lack of intake of animal numan nutrition. The first report that report n
from pnytate content, inadequate food intake occur man appeared in 1961, and a similar
food, high dietary nay in kwashiorkor
administration to children with indicate that
Toincreased faecal losses during diarrhoea. Zinc elenium Studies
supplementation in combination with oral rehydration
and
esuited in significant weight increase. in protein-eneroy
to significantly reduce the duratil may occur
iherapy has been shoWn numan selenium deficiency deficiency especially when
severity of acute and perSIstent diarrhoea and
to
malnutrition (66). Selenium
randomized control trials. deficiency, reduces antiboay
increase survival in a number oI Combined with vitamin E intake or
the integrity is recommended
Adeauate zinc intake 1S essentlal 1or maintaining production (68). 40 ug/day
of immune
system. Zinc affects multiple aspects of the selenium (11).
system, rom tne Darrier of the skin to gene
onulation within Iymphocytes. evere
immune maternal zinc Molybdenum
spontaneous abortion has been shoWn to
deficiency has been assoclatea with Excess absorption of molybdenum hand, deficiency or
lke anencephaly. Milder produce bony deformities. On
the other
and congenital mallormaions
has been associated with low birth molybdenum is associated with mouth and oesophageal
forms of zinc deficiency
weight, intrauterine growth
retardation and preterm cancer (67).
delivery. Several studies have indicated that zinc
supplementation may reduce the incidence of
clinical attacks Dietary antioxidants (9)
plays an important role as are both nutrients, viz.
of malaria in children. Zinc Antioxidants are substances which
suggest that zinc
E, C, B-carotene, selenium,
and non-nutrients, VIz.
antioxidant agent (65). These reports Vitamins benzyl
man (63). Zinc is phenols, tlavonoids, Coumarins,
deficiency may not be uncommon in plant and ellagic acids,
widely distributed in foodstuffs, both animal
and vegetable 1sothiocyanates, Cafteic, ferrulic, gallic
in vegetable foods is low dismutase and catalase
but the bioavailability of zinc Some enzymes like superoxide
fish are dependable mutase. Ihese antioxidants reduce the adverse
Animal foods such as meat, milk and Superoxides
for adults is 17 mg per day (ROS) and nitrogen
sOurces. Suggested daily intake effects of reactive oxygen species
per day tor during physiological or
or men, 13.2 mg per day tor women, 10 mg species which are generated in oxidant damage.
children and 5 mg for infants, Refer to Table
28 for details. pathological conditions and result
lactating women need ageing and several
Growing children and pregnant and Literature is replete with evidence that are due to chronic
more. Most human diets provide these amounts. diet/nutrient related chronic disorders vegetables, fruits,
exposure to ROS. It is well established that
tea and wine, and
Copper legumes, spices,beverages such as
body is estimated to be sources of AO, however scientific
Ihe amount of copper in an adult cereals are excellent is available only for
Derween 100-150 mg. Copper is widely
distributed in evidence for their protective role disorders. None of
narure. Even poor diets provide enough
copper tor human vegetables and fruits in several chronic so tar with nutrient
element 1s very rare. conducted
eeds. Deticiency or excess of this the randomized clinical trials a signiticant benefit in
nephrosis, Wilsonns AO supplements has demonstrated
ypocupremia occurs in patients with or two major trials in high-risk
and in intants fed community trials barring one
ISease and protein-energy malnutrition is
i 1Ong periods exclusively on cow's
milk. Neutropenia populations.
documented abnormality of copper deficiency. Experimental studies have amply indicated that both
Dest
ypercupremia may reflect excessive intake whicn may
pro-oxidant and AO have a fundamental role
in pathogenesis
copper cooking vesse15, Reactive oxygen species (ROS) damage the
u rom eating food prepared several in
chronic of diseases.
may be associated with disease,acute and bio-molecules such as DNA, protein, carbohydrates and
severe anaema lipids, and affect the enzyme
processes and genetic
ons (leukaemia, Hodgkin's
haemochromatosis, myocardial
intarctioon and
requirement for. nacie
OxIdatton products of bio-molecules
from an
odism (66). Estimated copper accumulate with age. ROS can arebe derived
dl is about 2.0 mg per day
daults enviornmental source also. There several endogenous
an important role
Cobalt and exogenous sources of ROS, which play
in diseases such as cardiovascular, cancer, cataract, diabetes
the human is as neuro-degenerative disorders and age-related masculopathy
n ny established function of cobalt in
a part of
the vitamin B, molecule, wi Chronic infections aggravate the damage. Further, research
pretormed. There is no evidence as ye
halt deficiency in this field has highlighted the mechanistic
details about th
n man
(10). Recently cobalt deficiency and in
cobaltcobalt iodine role of antioxidants in mitigating the damage.
tatio in # ecently Coo Droduce humans an
It is S 5O1 have shown to produce go
goitre for the tirst Free radicals produced during tissue metabolism
may be necessar for
their consequent damage are reduced by nutrier
stage ggested that cobalt by the
of hormone production. i.e., capture of iodine itS ntioxidants. The antioxidants, particularly vitamin E, C
gland (67).
Cobalt may interact with iodine and affect co-enzyme and giutathione seem to work in concert b
Ulzation
zation (10). recycling each other.
Chromium In healthy subjects, the dietar9 antioxidants from
6 mng
balanced diet with adequate fruitS and vegetables rangin
less then to take care
of chromium is
small, from 500-600 gm/d will probably be enough
ent intowo nt the occurrence of cellular and tissue defect

.
nterest n chromium is based on to Oxidant damage and repair
Sual glucose tolerance curves that are responsive However, certain groups o populations like pre-matu
chromi evidence tnat those exposed
Chromium Thus there is suggestive ana infants, smokers alconolcs, and
to carbohydrate environmental poilutants inciuding carcinogens, individua
5ulin s a role in relation
fun
lin function (10)
 TABLE 22

722 WEIGHTS (9) as

REFERENCE BODY determine the Body weghts
weighit largely Category teg
body Body weights and hge Grop
Age. gehder and of an individual. mutrition and 18 years 65.0
requiement health, represent
their state of
nulritio1al
heights oaf childrern
while
growth rate, attained
reflect
weight and heights of
individual with
adults
normal growth
Men
Women
>18 years 550 tire
by an and children of 0-6 months 58
what can be measurements of infants care and no
Anthropometric
families
good health
having access to treated as reference
irnfants 6-12 months 85
well to-do constraints are usually requirements 1-3 years 117
nutritional recommending nutrient reference
purpose of anthropometric 4-6 years 183
values. The these Children
is fo help atfaining 7-9 years 253
standards of infants
standard weights and heights Boys
10-12 years 349
wHO children 10-12 years 36.4
and pre-school published multi- Girls
has recently
Organization boys and 13-15 years 50.5 S
World Health
reference standards for 0-60 month
predominantly Boys
cenfre growth studies carried out among 13-15 years 49.6
on
girls, based breast-fed children in six
countries viz., USA, Girls
India. The median Boys 16-18 years 64 4
exclusively
Norway, Oman and (1-3 years) can 16-18 years 55.7
Brazil, Ghana, pre-school children Girls
infants and
weights of Indian children
be taken as
reference values for Source: (11)
man and woman
Reference Indian adult between 19-39 years and ENERGY
man is aged
"Reference BMI of and a
weighs 65 kg with a
height of 1.77 metre active work. Energy is a prime requisite for body function andstandae
grout
and physically fit for below a
20.75; free from disease in 8 hours of When a child's intake of food tals
of intake nere
is
day, he is engaged reference, growth slows, and if low levels
On each working involves moderate activity;
while
occupation which usually fail to meot
adult stature will be reduced. Similarly, adultsmay
hours in if
spends 8 hours in bed, 4-6
when not at work he and in active their food requirements they lose weight. This lead to
2 hours in walking
sitting and moving about, reduced ability to work, to resist intection, and underlio
weakened
household duties.
recreation or
19-39 years, non will to enjoy the normal satistaction of life. This sourro
"Reference woman is aged between 55 kg with a height the need for an adequate intake of food which is the
weighs
pregnant non-lactating (NPNL) and is free from disease and of all energy.
metre and a BMI of 20.95,
of 1.62 working day she is
physically fit for active work. On each Measurement of energy
which usually involves
engaged in 8 hours of occupation, work she spends 8 hours
moderate activity, while when not at The energy value of foods has long been expressed in
in bed, 4-6 hours in sitting and
moving about, 2 hours in terms of the kilocalorie (kcal). The kilocalorie is generally
walking and in active recreation or
household duties. expressed as "Calorie written with a capital "C" (74). This
which has
has been replaced by the "joule expressed as J,
infants accepted internationally. These units are defined as
been
The average of birth weight and body weight
at 6 months follows
the reference body weight for infants
is used for computing Joule, a physical unit of energy, is detined as the energyof
average of body
0-6 months of age. For 6-12 months, an taken for required to move 1 kg of mass by
1 metre by a force
weight at 6 months and at 12 months
is
1 Newton acting on it (One Newton is the force needed to
computation sec ).
accelerate one kg mass by 1 metre per
Children Kilocalorie (kcal) is defined as the heat required to raise
14.5°C to
For children 1-3 years of age, an average of body weight the temperature of one kg of water by 1°C from
at 18 months, 30 months, 42 months of WHO median 15.5°C. The unit kcal is still popularly used.
weight is taken (as mentioned above). The relationship between the two units of energy
is as

The reference body weight for children of 4-6 years are follows:
obtained by averaging the body weight of 44+, 5+ and
=4.184 KJ (Kilo Joule)
6+ years. Similarly for other age groups also the reference 1 kcal
body weights were obtained from the 95th centile value of 11KJ 0.239 kcal
body weights of rural India.
1000kcal 4184 KJ= 4.18 MJ (Mega Joule)
Adults 1 MJ = 239 kcal
The average of values for age category of 18-19, 20-24,
and 25-29 years was used for computing the reference Reference man and woman
formulated for a
weights for adult man and woman. Energy intake recommendations are protles
The summary of reference body weights for population in reterence man and a "reference woman" whosemade to
specified age groups is as shown in Table 22. are described, and then necessary adjustments are
 ENERGY 723

Subyeciswho deviate from the standard reference. This TABLE 23

was first devised by the FAO Committee on
requirernent (kcat d) as proprsed
by IMR 2021
procedureauirements in 1950 (75) and has
been in use ever
ergy Difference
calori ICMR ICMR
Age Category
since.
group 2020 2010

Energy
requirements Sedentary work 2110 2320 -210
of an individual is defined as 2730 20
The energy requirement Adult Men Moderate work 2710
level of energ intake from food that balances energy -20
that Heavy work 3470 3490
diture, when the individual has a body size and -240
enosition and level of physical activity, consistent with Sedentary work 1660 1900
n-term good health, also allowing for maintenance of 2130 2230 -100
Moderate work
ronomically essential and socially desirable activity. In 2850 -130
Heavy work 2720
Fhildren and pregnant and lactating women, it includes the
Adult Women 350
nergy needs associated with the deposition of tissues or Pregnant +350
cocretion of milk at rates consistent with good health (9). Lactating (0-6 m) +600 +600
The two standard deviation value is not added to the
+520
Lactating (7-12 m) +520
average requirement. Ihis is because the energy intake and
expenditure of an individual are finely balanced, and any 550 520 +30
0-6 months
Infants
surplus energy consumption will be stored as fat and a 6-12 months 670 670
continuous excess of intake will lead to obesity (9). Adults 1060 50
1-3y 1010
and even growing children are known to adapt either intake
to suit their output, or output to suit intake over a very wide Children 4-6y 1360 1350 +10
range. We do not have a proper understanding of the lower i 7-9 y 1700 1690
limit of adaption.
Boys 10-12 y 2220 2190 +30
Factors affecting energy requirements 10-12y 2060 2010 +50
|Girlsatin
Energy requirements vary from one person to another 2860 2750 +110
depending upon inter-related variables acting in a complex
Boys 9us 13-15 y
Girls 13-15 y 2400 2330 +70
way, such as age, sex, working condition, body composition,
physical activity, physiological state etc. All these factors Boys 16-18y 3320 3020 +300
lead to differences in food intake. 2500 2440 +60
Girls 16-18y
Currently, it is recommended that energy requirement
must be assessed in terms of energy expenditure rather than
Source: (11)
in terms of energy intake. It is a logical approach, where one
can specify the energy requirements in terms of energy
(+350 kcal daily throughout pregnancy) and lactation
(+600 kcal daily during the first 6 months, and +520 kcals
Ourput for productive work and leisure activity of adults and daily during the next 6 months) over and above their normal
nsSue deposition in infants, children and during pregnancy
requirements. This is to provide for the extra energy needs
and milk secretion during lactation. This does imply that
nere is a need to specify an appropriate body weight ot
associated with the deposition of tissues or the secretion of
milk at rates consistent with good health (11).
individual as well as the quantum of physical activity that is
considered 'desirable' for the same individual (11). (b) Children: Because of their rapid growth rate, young
children require proportionately more energy for each
Ihere are three important terms while defining energy kilogram of body weight than adults (see Table 28).
Denditure using physical activity estimations. These are
A problem that arises is in recommending intakes in
y cal Activity Ratio (PAR), Physical Activity Level (PAL)
Expenditure (TEE). The physical activity communities where a large number of children are
tal Energy is expressed as the ratio of the energy cost of an
underweight because of malnutrition. In order to provide for
AR "catch-up growth" during childhood, intakes should be
maalactivity per minute to the cost of the basal
metabolic rate (BMR)
per minute. based on age rather than weight where practical (77). The
ICMR standards are based on age, and not on body weight
Physical Activity Energy cost of an activity (except during the first year of life).
Ratio (PAR) per minute Children above the age of 13 years need as much energy
Energy cost of basal metabolism as adults. This is because they show a good deal of physical
per minute activity, almost equal to hard work by adults. This is also the
The PAR of age when puberty sets in and there is a spurt in growth and
is unit-less, and the distinct advantage an increase in metabolic rate. This fact should be
ergy expenditure of an activity in terms of PAR borne in
alues ro all mind when planning dietaries for children.
bodys relates to its use for both sexes, at all ages and at
sizes.
s is because these covariates appear in both (c) Adults: The energy requirements decrease with age
he num because of a fall in BMR and a decrease in physical activity
umerator and
Table ominator and cancel out (11):
23 shows the nergy requirement as, proposed by in most persons. In general, there is a 2 per cent decline of
2020, for resting metabolism for each decade for adults (31). The
Vulnerable arious age groups.fasssvi FAO/WHO committee suggested that after the age of
groups 40 vears, requirements should be reduced by 5 per cent per
a Pregnant energy each decade until the age of 60, and by 10 per cent for each
Tequirements and lactating mothers ,Thepregnancy decade thereafter (76).w
OWomen are increased. by
 for cheical
The aniro acitfor tarcves, and F0
esant
724 bvetween 50 and 66
are foods (69)
Indian diets, which
source of energy in are carbohydrate, ta, (i Net protein utilization (NP
the main plant food based, suppy energy at tte digestibility coefficient and biological vatue
eceminantlydietary fibre. They 100 (8). The NPU gives a more senre
compiete
Patein and protein quality than the amino acid f si
followin9 rates
4 kcal/a method that requires special laboratory facilitten
Protein kcal/g
Fat
9 sorty
Nitrogen retained by the body
4 kcal/g NPU
Carbohydrate Nitrogen intake
2 kcal/g important
Dietary fibre and considered
fibre forms an indigestible earlier
In calculating protein quality, 1 gram of
protei
Dietary and was neverfibres (soluble and assumed to be equivalent to 6.25 g of N
component of plant food These dietary
energy. yield short The protein requirement varies with the NPU
as source of fermentation in the colon and
insoluble) undergo proplonic and acetic acids protein. If the NPU is low the protein requirementan
such as butyric, colon cells and vice versa. The NPU of the protein of Indian diet in
chain fatty acids, as a source of energy by theenergy from
which are utilized to yield between 50 and 80
Hence they are known fibre.
and by the liver. and no energy from non-fermentable
fermentable fibre ot fibre is fermentable. (b) PROTEIN QUANTITY
In conventional
foods, 70 per cent is taken a5
conversion factor for fibre The protein content of many Indian foods has
In general, energy was not determined
Hitherto, dietary fibre determined and published in food composition tatiles
2.0 kcal/g. source of energy and there is a need to way of evaluating foods as source of protein is to detere alth
directly as a on the basis of their
recalculate energy vield of various foods fat and dietary what per cent of their energy value is supplied b
carbohydrates, proteins, protein content. This is known as Protein-Energy Rati. their
revised content of 1CMS

fibre (9). (PE ratio or percentage). atio The

energy in diets is carbohydrates gran
The main source of
These cereals constitute about Energy from protein
derived largely from cereals.provide 50-80 per cent of daily PE per cent x100
80 per cent of our diet and energycontribution from diets
Total energy in diet
energy intake. However,
varies very widely. Those belonging to loW income group This concept is useful because in many population grou
cent tat in their diet, whereas affluent adequate diet is not consumed to meet energy
have only 5 per cent their dietary energy eds
families derive as high as 30 per of resulting in energy deficits. The ratio of protein requirement pre
fat. Most families derive 10-12 per cent of energy from expressed as the ratio of protein calories to the enerm Tne
from gnancs
proteins (9). requirement is as given in Table 24.
Zgulteme

Nutritional individuality TABLE 24 trime

In normal individuals at all ages and of both sexes, there gper

Protein-energy ratio for difterent age groups (2020
is a large variation in energy intake but the
reasons for this
wide range of nutritional requirements are not known. The Group Protein Energy PE ratio
concept of nutritional individuality needs to be stressed, and requirement requirement of
its neglect may result in the over-feeding of some whose g/kg/d kcalkg/d requirement
needs happen to be less than the "average standard Pre-school childrenb
requirement" (78). 1-5 years 0.95 79 4.8

PROTEIN School children

6-10 years 0.91 68 5.4
Protein requirements vary from individual to individual. Adolescents
Apart from age, sex and other physiological variables, 11-17 years (Boys) 088 8
factors like infection, worm infestation, emotional 11-17 years (Girls) 0.86
disturbances and stress situations can affect a person s Adults
protein requirement.
Men (Sedentary) 0.83 32 10.4

Assessment of protein Women (Sedentary) 0.83 30 11.1

(a) PROTEIN QUALITY Men (Moderate active) ).83 39 8.5

Women
The quality of a protein is assessed by comparison to the 37 9.0
(Moderate active) 0.83
"reference protein" which is usually egg protein. Two
methods of assessment of protein quality needs mention PE Ratio = Protein Energy ratio; these values refer to the
(i) Amino acid score : It is a measure of the concentration requirement
of each essential amino acid in the test protein expressed as a Safe requirement of high-quality protein
a percentage of that amino acid in the reference protein. b Assuming moderately active children and adolescents

mg of amino acid per g of test protein Source: (11)

Amino acid score = X 100
mg of the same amino acid The protein-energy percentage value of some commony
per g of reference protein used foods is as shown in Table 25.
 PROTE 725

TABLE 25 TABLE 26
reguirenents Adiut
Essential amino acid (EAA)
Relative protein value of some foods FAOWHO/UNU 2007
ner cent of total energý supplied by protein Amino acid mggprotein
mg/kg/d
Nutrients per 100 g Energy from proteins 15
10
Protein Actual
PE%
Histidine 30
Food kcal 9 (kcal) Isoleucine
20 59
Leucine
39 45
100 20.0 80 80 Lysine
30 16
Fish 10
67 3.2 13 20
Methionine 6
Milk (cow)
350 21.0 84 24
Cysteine
4
22
Dhal 7.0 28 8 15
350 Methionine + Cysteine 23
Rice 1.6
Potato
100 Threonine 38
100 1.0 4 4
Phenylalanine + Tyrosine 25
Banana 6
160 0.7 2 Tryptophan 4
lapioca 39
26 277
Valine
cent, the subject will be unable
4 per 184
Ifthe PE is less than Total EAA
eat enough to satisty protein requirements. It is Total protein
0.66 g/kgd
recommended that protein should account for
to approximately 0.83 g/kg/d
cent of the total daily
10-12 per
energy intake. es Safe level of protein
(Mean t 1,96 x SD)

Dietary intakes Source: (11) essential

formed unless all the
express requirement in terms of grams New tissues cannot be requirement of EAA
It is customary to the diet. The
This principle applies to
all age amino acids are present inadvances in age. The quality of the
per kg of body weight.
additions in units of grams of decreases sharply as one infant than for the adult.
groups, although absolute lactation. is far more critical for the
pregnancy and diet
protein per day are made for
(11) suggested an intake of FAT
The 1CMR Expert Group
0.88 gram of protein per kg of
body weight for adult males is not known with certainty.
NPU of 65 for the dietary protein. The daily requirement of fat little over 50 per cent of the
and females, assuming a to a
for individuals of different During infancy, fats contribute down to about 20 per cent in
Table 28 gives the protein intakes intake. This scales
total energy (2020) has recommended
ages and physiological states. adulthood. The ICMR Expert Group as fat, of
intake of 20 per cent of the total energy intake of
Vulnerable groups an of fat intake should consist
which at least 50 per cent fatty acids. The requirement of
The protein requirements of
women are increased during vegetable oils rich in essential to
weight gain the 3 per cent energy intake
pregnancy. For 10 kg gestational essential fatty acids ranges from
22 g/day in 1st, 2nd and in young children.
requirement increases by 1, 9.5 and about 5.7 per cent of energy intake
and during lactation by their intake are as given in Table 27.
rd trimesters respectively;6 months), over and above Suggested levels of fat
9 per day (during 0 to TABLE 27
(2020)
normal requirements. dietary fat intake for Indians
Young children (0 to 6 years)
require proportionately Recommendations for
weight than adults. Fat from Visible fat
nore protein for each kilogram of body
Minimum
Age/Gender/ Physical
malnutrition. Physiological activity level of foods other
Ihey are more vulnerable to made Totalfat than visible %E g/p/d
has
Group (11) reasonable groups fats, oE
The ICMR Expert to (%E)
It seems
ecommendations for the elderly. not less than Sedentary
25
of the aged are Adult Man 10 10 30
ume that the requirement 31.
Moderate 20
40
nat for young adults, as shown in Table when Heavy
All estimates of protein
requirement are valid onlyenergy Sedentary
20
25
met. f the total 20 10 10
nergy requirements are fullyprotein will be diverted to Moderate
Heavy
30
dietary
dKe is inadequate some accepted that there are no body Adult Pregnant
30
wae energy. It is now intake.
a high protein women 20 10 10
stores which can be filled up by Woman
npresent there is no evidence that higher
the
intakes of
possibility cannot
Lactatin9
women
Human milk
30

greater benefit, although apparently choose to 0-6 months 40-60

berulod
Infants 10 25 25
they can,
ut. Most people, ifphysiological requirement. The 7-24 months 35
eak 25
the 3-6 years
question tein than intakes, far from being Children 30
beneremains whether high protein 7-9 yeaTS 35
10-12 years
eiclal, may actually be harmful (7) Boys
13-15 years 25 10 15 45
50
Amino acid requirements 16-17 years
essential 35
satisfy the need for on Girls
10-12 years
40
protein intake must also Committee Report of 13-15 years
aminoa WHO Expert estimates 35
The 2007 current 16-17 years
ids.
and Protein uirements gives adults.
(in mg/kg per day) for Source: (11)
hoacid requirements
2se are
oduced in Table 26.
 NUTRITION AND HEALTH
726 It has been said that food is not only
CARBOHYDRATE
nutrients open to statistical or dietarysle
carbohydrate in balanced simultaneously a system of communication b
The recommended intake of 50 to 80 per cent of customs, situations and behaviour.
diets is placed so as to contribute between
contain amounts more
total energy intake. Most Indian dietsper cent of total energy BALANCED DIET
than this, providing as much as 90
imbalanced. This
intake in some cases, which makes the diet A diet may be defined as the kinds of
needs to be corrected through nutrition education. food. w
energy, person or group lives. A balanced diet is do
The recommended dietary allowances for which contains a variety of foods in suched as
fat and minerals is summarized in Table 28. antities
protein, proportions that the need for energy, amino
minerals, fats, carbohyd and other
ids,
acids,vitzni z
OTHER RECOMMENDED INTAKES adequately met for maintaining health, vitalitrents
well-being and also makes a small provision
The recommended daily allowances of nutrients for
nutrients to withstand short duration of lean
Indians are as summarized in Table 28; Table 29 shows
acceptable macronutrients distribution range; Table 30 balanced diet has become an accepted means to c
population from nutritional deficiencies (79), sategad
.

shows summary of recommended intake of some of the

minerals and trace elements; Table 31 shows the daily In constructing balanced diet, the following
nutrients recommendation for the elderly and Table 32 should be borne in mind: (a) First and foremost,prindirp
shows Tolerable Upper Limit (TUL) for nutrients. requirement of protein should be met. This amountsthe
to
All nutritional requirements are interrelated. For example per cent of the daily energy intake. (b) Next comee 10-1
there is a close interrelationship between the energy and requirement, which should be limited to 15-30
er e
protein requirements, between requirements for daily energy intake (c) Carbohydrates rich in cent oithe
natural
phosphorus, calcium and vitamin D, between fats and should constitute the remaining food energy. The reqsir
vitamins, and between carbohydrates and vitamins. of micronutrients (lable 28, 29, 30 and 31) should he
be met

TABLE 28
Summary of RDA for Indians -2020

Age Category Body Protein Dietary Cal- Magn- Iron Zinc lodine Thia Ribo- Niacin Vit Folate Vit it
Group of work Wt Fibre cium esium mine flavin B6 B12 C
kg (g/d) (g/d) (mg/d) (mg/d) (mg/d) (mg/d) (ug/day) (mg/d) (mg/d) (mgd) (mg!d) (Hgd) (ug/d) (mgd) (ugd
E
Sedentary 32 1.4 2.0 14 1.9
Men Moderate 65 54.0 41 1000 440 19 17 150 1.8 2.5 18 2.4 300 2.2 80 1000 600
Heavy 52 2.3 3.2 23 3.1
Sedentary 25 1.4 1.9 11 1.9
Moderate 55 46.0 32 1000 370 29 13 150 1.7 2.4 14 19 220 2.2 65 840 600
Heavy 41 2.2 3.1 18 2.4
+9.5
(2nd
Pregnant b5 trimester
Women woman +22.0 1000 440 27 14.5 250 2.0 2.7 +2.5 2.3 570 +0.25 +15 900 600
10
(3rd
trimester)
Lactation
+17.0 2.1 3.0 +5 +0.26 330
0-6m
1200 400 23 14 280 +1.0 +50 950 600
7-12m +13.0 2.1 2.9 +5 +0.17 330
5.8 8.0 300 30 350 400
0-6 m* 100 0.2 04 2 0.1 25 12 20
Infants 400
6-12m 8.5 10.5 300 75 3 2.5 130 0.4 0.6 5 0.6 8512 30 350

1-3y 12.9 12.5 15 500 90 8 3.3 90 0.7 117 09 120 12 30 390

510 600
Children 4-6y 18.3 16.0 20 550 125 11 4.5120 0.9 1.3 9 1.2 135 12 35

23.0 1.6 11 1.5 170 2.2 45 630

7-9y 25.3 26 650 175 15 5.9 120 1.1
770 600
Boys 10-12y 34.9 32.0 33 850 240 16 8.5 150 1.5 2.1 15 2.0 220 2.2 55
790 600
33.0 31 850 250 28 8.5 150 1.41.9 14 1.9 225 2.2 50
Girls 10-12y 36.4
930 600
Boys 13-15y 50.5 45.0 43 1000 345 22 14.3150 19 2.7 19 2.6 285 2.2 70
890 600
1000 340 30 12.8 150 1.6 2.2 16 2.2 245 2.2 65
Girls 13-15y 49.6 43.0 36
1000 600
440 26 17.6 150 2.2 3.1 22 3.0 340 2.2 85
Boys 16-18y 64.4 55.0 50 1050
860 60
Girls 16-18y 55.7 46.0 38 1050 380 32 14.2 150 1.7 2.3 17 2.3 270 2.270
Adequate Intake (Al)
Source: (11)
 FAT 727

TABLE 29 TABLE 30
tAtADE} by rerernmended intakes far
tsle trat1utriert, tsrititiar TIge SumAry of eiernerits
árnd 17ere
atier hiierals
Nutrlents
Age group
S.No Minerals/
genRecommended intake
(per day)
1-2
years
3-1
years
Adults Pregnant and Trace Element T.l
lactating women 1000 mg/day
5-15 5-15 -15 Phosphorous
Protein (PE ralio)" 5-15
30-40 25-35 15-35 2000 mglday
TotalFat 20-35 Sodium
PUFA" 4-10 4-10 4-10 4-10 3500 mg'day
|n6 3 Potassium
n-3PUFA 0.5-1 0.5-1 0.5-1 0.5-1
2 mg/day
Carbohydrate 40-60 45-65 45-65 45-65 4 Copper
4 mg/day
Depends on prolein quality and fotal energy intake Manganese
#D-6to n-3 ratio should be between
5-10:1 50 uo/day
Chromium
ate: For good healih, adults should consume minimum of 100 to
corlbohydrates and alleast 20 g fats (food sources) Selenium 40 ug/day
130go
Source: (1) Source: (11)
TABLE 31
Daily Nutrient recommendations for the elderly in India-2020

Dietary Protcin Vit-A Thiamin Riboflavin Niacin Vit-C Vit-B, Folate Vit-B,, Vit-D Calcium Magnesium Iron Zinc lodine
NutrlentoHEnergy (mg) (mg) (ug)
(Kcal) ibre j (g (4g B,mg) B,(mg)(mg) (mg). (mg) (4g) (IU) mg (mg)
- 370 11 14 95
EAR 1700 42.9 460 1.6 12 65 1.6 250 2.0 400 800
Men 19 17 150
260 Y1S RDA 32 54.0 1000 14F2.0 14 80 1.9 300 2.2 800 1200 440
310 11 11 95
Women
EAR 1500 36.3 390 1.1 1.6 9 551.6 180 2.0 400 800
19 13.2 150
60 Y18
RDA 25 45.7 840 1.4 1.9 11 65 1.9 200 2.2 800 1200 370
Thece ls no
RDAfor Energy. The EARis equivalent io the Estimated Energy Requirements (EER)
Source: (11) it
TABLE 32
Tolerable Upper Limit (TUL) for Nutrients -2020
Zinc lodine Niacin Vit. B Folate Vit. C Vit. A Vit. D
Age Cotegory Protein Calcium MagnesiumIron (ug/d) (mg/d) (Hg/d) (IU/d)
Group of work (PE ratio) (mg/d) (mg/d) mg/d) (mg/d)4g/day) (mg/d) (mg/ d)

Men Sedentary
Moderale <40% 2500 350 45 40 1100 1000 2000 3000
Heavy auhe 35
05 100 4000
Sedentary
40 1100 1000 2000 3000
Moderate s40% 2500 350 ta45
Heavy
Pregnant 40 1100 1000 2000 3000 4000
Women <30% 2500 350 45
Woman
Lactation
2500 350 45 40 1100 1000 2000 3000 4000
0-6 months s40%
7-12 months
0-6 months <15% 40 600 1000
Infants
6-12 months <15% 40 600 1500
|Chldren
1-3 years <15% 65 40 1 200 350 600 2500
1500
4-6 years <15% 110 40 12 300 550 900 3000
2500
7-9 years 110 40 12 400 300 800 900 3000
<15% 2500
600-800
Boys
10-12 years 350 40 23 600 (9-17y) 1050 1700 4000
<15% 3000
Gids 10-12 years 350 40 23 600 1300 1700 4000
<15% 3000
Boys
13-15 years 350 45 34 900 1550 2800 4000
Girls <15% 3000
13-15 yearsS 350 45 34 900 1800 2800 4000
s15% 3000
Boys 45 34 1100 1950 2800
16-18 years <15% 3000 350 4000
Glris
years 350 45 34 1100 2000 2800 4000
6-18 15%3000 judged to be unlikely to lead to adverse health
maximum level of halbitual intake from all sources of a nutrient or related substance
effects

Note:1
e
humans
Valucs are only for non-dietary pharmacological doses.
Source:
(11)
 750 NUTRITION AND HEALIH
in 1970 On
Health and Family Welfare National
developed at the Ine the basj
Anaemia Mukt Bharat Strategy (175) technology
evaluation of the programme
The Anaemia Mukt Bharat Strategy
is a universal strategy at Hyderabad. An utrit
interventions revealed a significant reducti details).
in vitamin deficenoyn
ho
and will focus on the following six children (see page 705, 706 for
folic acid supplementation.
1. Prophylactic iron and
2. Prophylaxis against nutritional anaemia
2. Deworming.
3. Intensified year-round behaviour
body, smart
change communication
mind) focussing on four key
In view of its public health importanco a
programme for the prevention of nutritional ang ia
, natiOna
campaign (solid
compliance to iron folic acid launched by the Govt. of India during the forth Five was
behaviours (a) improving
supplementation and deworming; (b) appropriate infant
(c) increase in intake
Plan. The programme consists of distribution
ofiron e
and young child feeding practices;
diversity/quantity/ folic acid (folifar) tablets to pregnant women and young and
of iron-rich food through diet children (1-12 ears). Mother and Child Health + (MCH
focus on harnessing
frequency and/or fortified foods with
delayed Centres in urban areas, primary health centres in in rural ateas
locally available resources; and (d) ensuring and ICDS projects are engaged in the implement
(by 3 minutes) in health ofthis
cord clamping after delivery programme. The technology for the contro of
facilities. through iron fortification of common salt haenaemia
4 Testing and treatment of anaemia,with using digital methods developed at the National Institute of Nttbeen ition
and point of care treatment, special focus on Hyderabad (see page 732 for more details) tt
pregnant women and school-going adolescents.
5. Mandatory provision of iron and folic acid fortified foods 3. Control of iodine deficiency disorders
in government-funded public health programmes.
of non-
The National Goitre Control Programme was launched
the Government of India in 1962 in the conventional
ce
.
6. Intensitying awareness, screening and treatment
nutritional causes of anaemia in endemic pockets, with belt in the Himalayan region with the objective
special tocus on malaria, haemoglobinopathies and identification of the goitre endemic areas to supply 10dized
fluorosis. salt in place of common salt and to assess the pact of
goitre control measures over a period of timne.
The Anaemia Mukt Bharat Strategy will be implemented
in all villages, blocks, and districts of all the states/UTs of Surveys, however, indicated that the problem of goitre
India through existing delivery platforms as envisaged in the and iodine deficiency disorders was more widespread than
National Iron Plus Initiative (NIPI) and Weekly Iron Folic was thought earlier, with nearly 145 million people estimated
Acid Supplementation (WIFS) programme (175). to be living in known goitre endemic areas of the country. As
a result, a major national programme the IDD Control
was mounted in 1986 with the objective tn
COMMUNITY NUTRITION PROGRAMMES Programme
replace the entire edible salt by iodide salt, in a phased
The Government of India have initiated several large- manner by 1992 (see page 494, 733 for more details).
Scale supplementary feeding programmes, and programmes
aimed at overcoming specific deficiency diseases through 4. Special nutrition programme
various Ministries to combat malnutrition. They are as This programme was started in 1970 for the nutritional
shown in Table 38. benefit of children below 6 years of age, pregnant and
nursing mothers and is in operation in urban slums, tribal
TABLE 38 areas and backward rural areas. The supplementary food
Nutrition programmes in India supplies about 300 kcal and 10-12 grams of protein per
Ministry
child per day. The beneficiary mothers receive daily 500 kcal
Programme
and 25 grams of protein. This supplement is provided to
1 Vitamin A prophylaxis Ministry of Health and them for about 300 days in a year. This programme was
programme Family Welfare originally launched as a Central programme and was
2 Prophylaxis against Ministry of Health and transferred to the State sector in the fifth Five Year Plan as
nutritional anaemia Family Welfare part of the Minimum Needs Programme (168). The main
3. lodine deficiency disorders Ministry of Health and aim of the Special Nutrition Programme is to improve the
control programme Family Welfare nutritional status of the target groups. This programme i
Special nutrition Ministry of Social Welfare gradually being merged into the ICDS programme.
programme
Balwadi nutrition programme Ministry of Social Welfare 5. Balwadi nutrition programme
6. 1CDS programme Ministry of Social Welfare
7 Mid-day meal programme Ministry of Education This programme was started in 1970 for the beneftit
Mid-day meal scheme Ministry of Human children in the age group 3-6 years in rural areas. It is und
8.
Resources Development the overall charge of the Department of Social Welfare. Fo
national level organizations including the Indian Counci
Child Welfare are given grants to implement the program
1. Vitamin A prophylaxis programme Voluntary organizations which receive the funds are actv
One of the components of the National Programme for involved in the day-to-day management. The programme
Control of Blindness is to administer a single massive dose implemented through Balwadis which also provide p
of an oily preparation of vitamin A containing 200,000 IU primary education to these children. The food supplem
(110 mg of retinol palmitate) orally to all pre-school children provides 300 kcal and 10 grams of protein per child per
in the community every 6 months through peripheral health Balwadis are being phased out because of universallzad
workers. This programme was launched by the Ministry of of ICDS.
 ANNEXURES 753
ANNEXURE-2
BALANCED DIETS
(The quantities are given in
grams)
Adult man
Adult woman Children Boys Girls
d ltem Seden Moderatc Heavy
tary Seden Moderate Heavy 1-3 4-6 10-12 10-12
work work tary work work years years years years
reals 460 520 670 410 440 575 175 270 420 380
Ises 40 50 60 40 45 50 35 35 45 45
aly vegetables 40 40 40 100 100 50 40 50 50 50
her vegetables 60 70 80 40 100 20 30 50 50
oofs and tubers 50 60 80 50 50 60 10 20 30 30
k 150 200 250 100 150 200 300 250 250 250
il and Fat 40 45 65 20 25 40 15 25 40 35
ugaf or Jaggery 30 35 55 20 20 40 30 40 45 45
outce f1358)

ANNEXURE-3
Suggested substitution for non-vegetatians
iood item which can be deleted irom non-vegetarian diets Substitution that can be suggested for deleted
item or items

S0% of pulses
(20-30 g)
1. One eg or 30 g of meat or fish
2. Additional 5 gof fat or oil
100% of pulses 1. Twa e2gs or 50 gof meat or lish
g
4040
2. One ega nlua 30 q meat 10 gof fat or oil

Source: (1.38)

ANNEXURE-4
Low cost lndian vegetarian high protein diet for an adult woman
during 2nd and 3rd irimester of pregnancy {10 kg GWG)

Food grouP 2nd trimester Digestible protein 3rd rimester Protein

Composition Amount (g'd) content" (g/d) Amount (g'd) content
Cresls & Milets 325 24 260 20
Pulses (legumes) 11 80 14
Green lesfy
Vegetables (GIVs) 250 250
Dther vegetables 100 9 100 9
Roots & tubers
50 30
Fruits
50 50
Milk and
milk 9 750
products 300 23
Fats& oils 22
30
ugar & Jaggery 20
5

tnergy (kcal} 2031

2019
Protein 65
igl 54
PERatio 13
1
rice: wneat: mile1s (HaguBajra/Jowar). For calculation purposo
Valuesnd millets are presumed to be in the ratio 40:40:20 for
potao an gua pesenS gTeen iealy vegetables, other vegetables ro
nd a three millets are averaged. Spinach, french beans,foods: IFCT, 2017,
of
bRe d ruits respectively. Source of nutritive values
digestible protein content of the diet. Protein contents of each food group (except for GLVs, roots and tubers. fruits). are
Crecn
Ced for irue faecal digestibilüiy values
Sourte:
(11)
 NUTRITION AND HEALTH
754 and serum triglycerides. This alsob
ANNEXURE-5 cholesterol in blood. Simple modificaates H
Exercise and physical activity deliberately climbing up the stairs inst ead in fieste
a and walking for short distance instead of of u3ine
Individuals over the age of 20 years should undertake could also immensely help in increadiing
reasing
moderate
minimum of 30 minutes of physical activity of if not all activity. our
intensity (such as walking 5-6 km/hr) on most,
can be obtained Exercise programme should include wa up Caerea
days of the week. Greater health benefits or more down' periods each lasting for 5 minut
by engaging in physical activity of longer duration and e
vigorous intensity (such as jogging, running, cycling
and the intensity of exercise should ensure 60.ng
swimming) heart rate
embarking on a physical activity Previously inactive men over the
Sedentary people age of
programme should undertake a moderate intensity activity women over the age of 50 years and peo 40
the chronic diseases like heart disease at high
of short duration to start with and gradually increase
activities like first consult a physician before engagina inetes sh
duration or intensity. Other day-to-day
walking, housework, gardening, will be beneficial not only of vigorous physical activity such as progam
running
n weight reduction but also for lowering of blood pressure swimming.

Computation of energy expenditure of adult

Indian population using factorial approach

Major lifestyles, energy expenditure

(PAR values)
Main daily activities Duration (h)
Sedentary Moderate Heavy or
active vigorousty
active

Sleep 8 1.0 1.0

1.0

Occupational activity 8 1.3 2.5 4.1

Non-occupational activity 8 1.9 1.9 19

Mean 1.41 1.80 2.33

Non-occupational activity

Personal care 1.6 1.6 1.6

Eating 1.2 1.2 1.2

Commuting to work by bus or 1 2.0 2.0 2.0

by vehicle or by walk

General household or other 2 2.0 2.0 2.0

activities

Walking at various speeds 1 3.4 3.4 3.4

without load

Light leisure activity 2 1.4 1.4 14

Mean non-occupational activity 8 1.9 1.9 19

Men body wt. (65kg),

3509
BMR (1506kcal) 2123 2711

2759
Women: body wt. (55kg), 1670 2131
BMR (1184 kcal)

Source: (11)
 MANACEMINT asma p
Part 2 of TSDFs or plasr
WARIE disposalfacility
HSPEA. 1200"C discarded chemical wast
888 standards as and when
1anagement R Residual
or
Chemical sludge ed
1315 infectants andtreatment, storad ge
as per plastie waste
beprevailing hazardous wasteaste should be
and
bays shall Sodium the far to haa
plast then the 10% twenty such ca5e, slorage and disposal ugh
shall
il
Pbshed, be appicalle. using at least for
chlorinereagent that
reatment,
common bio-medical
waste treatment andduposa
rules Tyeatment 1esidual
chemlcal microp
hemieal having 30% equivalent efflciency for only pre-treatment of laboratorry waste micr
typochlorite other reduction On-sjte
or any
miutesdemønstrate Log,,4 prevent 9. waste, blood samples, bloo ood bags disn
to guidelines of World Health Gr
should to on extent sterilized
terilized as per
s the
National IOS
be Control Organisation and th
vganisvs shredding must incineration,
Mutilation or reuse bio-medical waste treatment an
pretreatmentbefore infectious waste
nauthorited chemical highly bio-medical facility, incinerator is alloe
be no lab and any wed. Howen
Installation of in-house
ty noser
will mierobiological, incineratlon ofhazardous waste Unite
here except tor from hazardous 10. 1s no common omedical facilft
biom
(ash through
cineration ashbe disposed facility, prescribed
disposal
If toxlc or limits as
case there
same may be from
installed
the
by the
State Pollution
Contafter
ard
he
UNISDR)
functio
(2
waste) shall and handling and authorization
treatment, storagepresent beyond
the either mutilatedleak
or ne esshould
pune
(management, revised from should betamper widespread
are Syringes proof, ak proof the
constittents Hazardous Waste or as 11, stored in Wherevor and
the movement) Rules, 2008, and or storage.
for sharpfacility it shall be ihOCCupp osses
9ven in
transboundary Medical proof containers communit
period (as per the time to disposal
not linked to a to steril1ze and dispose in tb nanne UNISDR
from
time to time, below the viability1971, amended waste, Such of the Occupier
many
Dead foetus of Pregnancy Act anatomical common prescribed.
generatedin householde
Termination considered as human operator of yellow waste ot ditio
tme can be
be handed
the
over to disposal facility in
termination of
12. Bio-medical
healthcare activities separate bags
as per thes
shall De segregated or contain capacity
waste shouldwaste treatment and medical over in Bodioe
bio- medical copy of the
official or the
medical and handed collectors. Urban Local treatme negafiv
a rom the
obstetrician
establishment municipal waste common bio-medical waste
bag with the Ma ife, in
pregnancy certificate hospital or
healthcare over to tie up with to pickup this waste from the
superintendent of shall not be handedThese shall disposal facility (MRF) oT from the house hold schedule direct physie

drug vialsunder any circumstances. Recovery Facility in this pra

necessary disposalat manner as prescribed to
(7) Cytotoxic
unauthorized personmanufacturers for final disposal in the econ
may be sent for
back to the
be sent point. As a second option, these treatment and
waste
a single common bio-medical all aspects of O
incineration at on g
COVID-19 has had a serious impactexception. Therenave h
no
waste management potentially infected waste
is
into
should be segregated
waste the society, and amount of treatment
bio-medical waste generation of the increased handling and
The of disposal of been an additional, careful sanitation
containers/bags at the pointof containers used for label for which requires
sateguard the waste handlers and facilities. Fot
the type shows the processes to healthcare
colour coding and in Fig. 2 which associated with such introducedto
as shown
waste are symbol and cytotoxic hazard symbol workers colour-coded bins must be
non-washable. should not be
bio-hazards visible and operated lids in Generalsolid waste fluids. Wet
prominently
should be Symbol avoid contact patient's secretions and bodyAl the wasta
Cytotoxic Hazard contaminated by securely.
Bio-hazard Symbol solid waste bags must be tied measures like hand
and dry follow the
preventive personal
handlers must gloves and mask, and other
washing, using
protective equipments.
(Management
References Bio-Medical Waste Bhopal
A.K. (1998). House,
1. Sharma, Rules, 1998, Suvidha Law P (1999
Handling) Rushbrook,
Cirouit, E., and Health-Care
Activities,
2 Pruss, A., of Wastes
from
Management Bangalo
Cytotoxic Wastes in
1999
(1995). Disposal
of Hospital Mand
Bio-hazard Rao, H.V.N. Environment, Appropriate Waste
3rd Inte
HANDLE WITH CARE heir Impact on
for Developing Countries,
Technical Papers
lechnologies Nagpur,
FIG. 2
1995,
Conference 25-26 Feb Ministry of Environment,
Ga2ete
r
(2016).
Schedule I Govt. of India Notification published in the
containers/bags
4 Climate Change, Management Rule 2016.
bio-medical waste Bio-Medical Waste
Label for visible,
non-washable and prominently
Note: Label shall be
 ALCO TOLISM AND DRUG DEPENDENCE 933
TABLE 2
willi a high risk lor drug abuse on cocaine, ATS and Hallucinogens is extremely smal
aclors associat In comparison to the size of country's population.
. Nationally, it is estimated that there are about 8.5 lakh
unemployment certain occupations group of drugs
from home
people who inject drugs (PWID). Opioid
living away
(lourism, drug production or sale)
are predominantly injected by PWID (heroin -
46 per
migration to cities areas with high rates of crime cent). A
control or vice cent and pharmaceutical opioids - 46 per risky
relaxed parental substantial proportion of PWID report
alienation from
family areas where there are drug- numbers of PWID
using gangs injecting practices. High
early exposure
to drugs are estimated in Uttar Pradesh, Punjab, Delhi, Andhra
leaving sch0ol
early areas where delinquency is
Pradesh, Telangana, Haryana, Karnataka, Maharashtra,
-

one commOn
broken homes; Manipur and Nagaland.
parent families
environments
large urban Prevention
drugs are sold,
areas where
raded, or produced Approaches to prevention of drug dependence shoulda
have realistic aims. Over-ambitious hopes of eradicating
to polici1es
Source: /8) drug problem in a short time are likely to lead
that are unrealistic and self-discrediting. Changes in culture
Magnitude of substance abuse in India (18) attifudes and alteration in relevant aspects of the

A National Survey was conducted between December

environment can be brought about only slowly.
of
9017 and October 2018. The primary objective of the
Legal approach: The legal control on the distribution an
survey was to assess the extent and pattern of substance use drugs, when effectively applied has been and remains
ineach state/UT. The key findings of the use of psychoactive
important approach in the prevention of drug abuse. Controls
Substances in India is as follows (18). may be designed to impose partial restriction or to make a
Alcohol is the most common drug completely unavailable. Legislation may be directed at
1. Alcohol
Dsychoactive substance used by Indians. Nationally, controlling the manufacture, distribution, prescription, price
about 14.6 per cent of the population between 10 and time of sale, or consumption of a substance.
75 years of age uses alcohol. In terms of Legislation restricting or prohibiting advertisements that
absolute numbers, about 16 crore persons consume directly or indirectly promote use of tobacco and alcohol has
alcohol in India. It is considerably higher in men (27.3 been increasingly common in recent years. The antismoking
per cent) than women (1.6 per cent). Among alcohol measures suggested are : (a) prohibition of the sale of
users, country liquor or desi sharab (about 30 per cent) tobacco products to minors; (b) restriction on the sale of
and spirit or Indian made foreign liquor (about 30 per cigarettes from automatic vending machines; (c) prohibition
cent) are predominantly consumed beverages. Of the of smoking in schools and other places frequented by young
14.6 per cent (16 crore) users, 5.7 crore (5.2 per cent) people; (d) prohibition of smoking in public; (e) prohibition
are problem users and 2.9 crore (2.7 per cent) are of cigarette advertising at times, and in places and ways,
dependent users. calculated to ensure its maximum impact on adolescents;
(f) establishment of mandatory public health education on
2. Cannabis Cannabis are the next commonly health consequences of smoking: (g) insisting on the placing
used bstance. About 2.8 per cent of the population
of mandatory health warning on cigarette packets.
(3.1 crore individuals) report having used any
cannabis product within the previous year. The legal The minimum age at which minors may legally have
orm (bhang) was used by 2.2 crore (2 per cent) and access to alcoholic beverages, has been raised in some
1.3crore (1.2 per cent) persons used illegal form (ganja countries. There is also legislation controlling the
and charas). Out of 3.1 crore cannabis users, about distribution of alcohol in some countries. Mandatory jail
72 lakhs are problem users and 25 lakhs are dependent sentences for drunken driving have not been very effective.
users. The highest use of cannabis was recorded in Uttar Educational approach : Educational approaches to the
Pradesh, Punjab, Sikkim, Chhattisgarh and Delhi. prevention of drug use and drug-related problems have been
3. Opioid: About
2.1 per cent (2.3 crore) population in used in many countries. Common approaches have
ndia use opioids which includes opium or its varíants included educational programmes for school children and
heroin or its public information campaigns on electronic media. General
Ke poppy husk known as doda/phukki,
principles of communication can be applied to increase the
impure form smack or brown sugar and a variety
9pnarmaceutical opioids. Out of 2.3 crore users, about effectiveness of educational approach. The message should
a are problem users (opium 11 lakhs, heroin 63 be clear nd unambiguous to the intended audience, and
lakhs are come from credible source of intormation. The message
S and pharma opioid 25 lakhs), and 28 should also provide specific advice, rather than general, and
dependent users.
as far as possible the information should be new to th
S1zeable number of people use other drugs like audience and should be capable of provoking discussion o=
ves and inhalants. In the general population, action. Educational approach should not be planned an
o .2 per cent of Indians need help for their carried out as isolated activity. To be effective, sucF
esti use problems. At the national level, an approaches should be regarded as a part of integrated plar
hol.ted 4.6 lakhs children and 18 lakhs adults need of action involving other strategies
eD for their inhalant use (harmful use/dependence
n termsof absolute numbers,states with Community approach: The non-medical use of the drug
individually as well as in its mass appearance involves
tePopulation of children needing helpMaharashtra, for inhalant
use complex interaction ot drug, man, and his environmen
are:
Delhi Uttar Pradesh, Madhya Pradesh, including social, economic, cultural, political and othe
and Haryana. The number of people dependent
 970 HEALTH FLANNG AND MAAGEMET
strong1
establish registries for diseases of public
health (1) Water supply and sanitation; arOgnized
1he non-
importance by 2020. (2) Control of communicable diseases;
Establish federated integrated health information ar
(3) Medical education, training CVen
architecture. health information exchanges and and research:
national heaith information networ 2025. (4) Medical care including hospitals, aS
primary health centres: dispensari. ntry
aries servic
HEALTH PLANNING IN INDIA (5) Public health services; and
nfthCiven/
Health planning in India is an integral part of national (6) Family planning: and
ut
s/orm p
socio-economic planning (2, 13). The guide-lines for (7) Indigenous systems of medicine. alforda
national health planning were provided by a number of
commiees dating back to the Bhore committee in 1946. All the above sub-sectors
have
d learP
These committees were appointed by the Government of consideration in the Five Year Plans. received d
However, the e ue Oneol
India from time to time to review the existing health has changed from Plan to Plan HSTem
depending
consideranasis neansn<
situation and recommend measures for further action. felt-needs of the people and technical
the
The Alma-Ata Declaration on primary health care and the give effect to a better coordination dined
National Health Policy of the Government gave a new State Governments, a Bureau ot between the Centr 10 rdabl
atloraal
Planning
1965 in the Ministry of Health, Govt. was constitutoa pETcenta
direction to health planning in India. making primary health
care the central function and main focus of its national function of this Bureau
is
Health Five Year Plans. The Health
of India. Tho
compilation of
n
Nafio
HLEG)
health system. The goal of national health planning in India Plan is implement
Ensuri
was to attain Health for All by the year 2000. at various levels, e.g., Centre, ented the
Village. State, District, Block of
and Jender
PLANNING COMMISSION 4ppros
preves
The Government of India set up a Planning Commission FIVE YEAR PLANS (26, 27,
28)
in 1950 to make an assessment of the material, capital and
human resources of the country, and to draft developmental The five year plans were conceived to re-build indi
to lay the foundations of industrial progress rural India
plans for the most effective utilization of these resources. In and to secure the
1957. the Planning Commission was provided with balanced development of all parts ot
a Recognising "health" as an important contributorythe countru.
Perspective Planning Division which makes projections into factor in
the future over a period of 20 to 25 years. The the utilisation of manpower and the uplitting of
Planning condition of the country, the Planning Commissionthe economic
Commission consists of a Chairman, Deputy Chairman and gave
5 members. The Planning Commission works through considerable importance to health programmes
3 major year plans. The broad objectives of the health in the five
divisions Programme Advisers. General during the five year plans have been
programmes
Secretariat and Technical Divisions which are responsible for
scrutinizing and analyzing various schemes and projects to (1) Control or eradication of major communicable
be incorporated in the Five Year Plans. Over the years, diseases;
the (2) Strengthening of the basic health services
Planning Commission has been formulating successive Five through the
Year Plans. By its terms of reference. the establishment of primary health centres and subcentres
Planning (3) population control; and
Commission also reviews from time to time the progress
made in various directions and to make recommendations to (4) development of health manpower resources
Government on problems and policies relevant to the
pursuit of rapid and balanced economic development. The Twelfth Five Year Plan (2012-2017)
planning process was decentralised towards Decentralised The health of a nation is an essential component of
District Planning by the year 2000.
development, vital to the nation's economic growth and
internal stability. Assuring a minimal level of health care to
NITI AAYOG the population is a critical constitutent of the development
process.
Government of India has established NITI Aayog
(National Institution for Transforming India) to replace Since independence, India has built up a vast health
Planning Commission on 1st January 2015. It will seek to infrastructure and health personnel at primary, secondary
provide a critical directional and strategic input into the and tertiary care in public, voluntary, and private sectors.
development process. NITI Aayog will emerge as a "think- For producing skilled human resources, a number of medical
tank" that will provide Governments at the central and state and paramedical institutions including Ayurveda, Yoga and
levels with relevant strategic and technical advice across the Naturopathy, Unani, Siddha and Homeopathy (AYUSH
spectrum of key elements of policy. In addition, the NITI institutions have been set up.
Aayog will monitor and evaluate the implementation of Considerable achievements have been made over the last
programmes, and focus on technology upgradation and six decades in the efforts to improve health standards, such
capacity building. as life expectancy, child mortality, infant mortality, arn
maternal mortality. Smallpox, guineaworm, poliomyeu
HEALTH SECTOR PLANNING have been eradicated. Nevertheless, problems abou
Malnutrition affects a large proportion of children.
Since "health" is an important contributory factor in the unacceptably high proportion of the population continues
apc
utilization of manpower, the Planning Commission gave suffer and die from new diseases that are emerging, ons
considerable importance to health programmes in the Five from continuing and new threats posed by the existing
Year Plans. For purposes of planning, the health sector has Pregnancy and childbirth relatedcomplications a
been divided into the following sub-sectors (25). contribute to the suffering and mortality.:
 972 LALI PLANNING ANID MANAGEMENT
HEALTH SYSTEM
TABLE 4 IN INDIA
Achievements during the plan periocds
India is a Union of 29 States and 7 Union
1st Plan 3 years action the Consitution of India, the States aro erritories
1951-5 agenda 2019 in matters relating to the delivery of inden
1. Primary Health Centres Each State, therefore, hasdeveloped own h careto ependenn
725 24,855 its thepeor
2. Subcentres NA 157,411
care delivery, independent of the Central Gosystemofhea
health
3 Community health centres 5,335
Central responsibility consists mainly
of nmen
policy The
4. Total beds (2017) planning, guiding, assisting, evaluating, co
125,000 713,986 and makn
Ordinating
5. Medical colleges 42 529 work of the State Health Ministries, so
that
6. Annual admissions 3,500 58,756 cover every part ot the country, and no Stato 1hea Servie he
tvces
in medical colleges want of these services, The heal system lags eind
in India lor
7. Dental colleges 7 313 links, i.e., Central, State and Local or
peripheral has3main
8. Allopathic doctors 65,000 1,154,686
9. ANMs
Nurses (registered) 18,500 1,980,526 I- AT THE CENTRE
10. (registered 12,780 860,927
11. Health visitors The official "organs" of the health system
578 55,675 at the na
12. Health Workers (F) level consist of (1) The Ministry of Health
:
234,220 antional
(in position) Welfare; (2) The Directorate General of Health Setedmuly
13. Health Workers (M) (3) The Central Council of Health and Family
59,348 Welfare
(in position)
14. Block Extension Educator 1. Union Ministry of Health and Family Welfar
3,512
15. Health Assistant (M)
13,446
(in position) (1) ORGANIZATION
16. Health Assistant (F}/LHV
13,786 The Union Ministry of Health and Family Welfare
(in position) is headed
17. First Referral Units by a Cabinet Minister, a Minister of State and a Deputy
3,204 Health
Minister. These are political appointments. Currently,
Source: (31) Union Health Ministry has the
the following departmenis
(1) Department of Health and (2) Department
The investments during different plan periods is listed on of Family
page 600. Welfare. The Health Department is headed by a Secretary
to
the Government of India as its executive head, assisted by
Three Year Action Agenda of Niti Aayog joint secretaries, deputy secretaries anda large administrative
(2017-18 to 2019-2020) staff. The Department of Family Welfare was created in 1966
within the Ministry of Health and Family Welfare. The
On 1st January 2015, The National Institution for
Secretary to the Govt. of India in the Ministry of Health and
Transforming India (NITI Aayog) came into existence as the Family Welfare is in overall charge of the Department of
Government's premier think tank. It was told to prepare a Family Welfare. He is assisted by an Additional Secretary&
15 year vision, Seven Year Strategy and Three Year Action Commissioner (Family Welfare), and one Joint Secretary
Agenda documents. Accordingly, the Vision Strategy and
Action Agenda is a departure from the Five Year Plan (2) FUNCTIONS
process. The 12th Five Year Plan was the last of these plans.
The functions of the Union Health Ministry are set out in
The Three Year Action Agenda offers ambitious proposals
the seventh schedule of Article 246 of the Constitution o
for policy changes within a relatively short period. The India under (a) the Union list and (b) the Concurrent lst.
proposed Agenda is wide-ranging and the specific health
goals to be achieved by the year 2020 are as follows (30): (a) Union list: The functions given in the Union listare
( International health relations and administraio h
1. Reduce maternal mortality ratio to 120/100,000 live
quarantine (2) Administration of central institutes sucn
births (2013 estimate: 167/100,000 live births). All India Institute of Hygiene and Public Health. ola
2. Reduce infant mortality rate to 30/1,000 live births National Centre for Disease Control, Delhi, etc. (31 Promat
(2013 estimate: 40/1,000 live births). through research centres and other Dou
Reduce under 5 mortality rate to 38/1,000 live births
research
4) Regulation and development of medical, pharmatend
(2015 estimate: 48/1,000 live births). aental and nursing professions (5) Establishmend
4. Reduce Total Fertility Rate to 2.1 (2013 estimate: 2.3). maintenance of drug standards (6) Census, and coleanand
5. Reduce incidence of TB to 130/100,000 (2015 estimate: publication of other statistical data (7) Immiramines
of n
217/100,000). emigration (8) Regulation of labour in the working other
h
and oil fields and (9) Coordination with States and wlu
6. Reduce incidence of malaria (annual parasite incidence)
ministries for promotion of health.
to less than1/1,000 in 90% of districts (2016 estimate:
74% of districts have achieved an API of less than 1). b) Concurrent list: The functions listeation and
Unio
7, Eliminate Kala-azar (2015 estimate: 80% of endemic Concurrent list are the responsibilit of both theStates have
blocks have eliminated) and Lymphatic Filariasis (2015 State governments. The Centre and the the laterrare
estimate: 87% of endemic districts have eliminated). simultaneous powers of legislation; the powers of
restricted to the framework of such legislatio. includes
8. Reduce premature mortality from cardiovascular undertaken by the Centre. The diseases from
diseases, cancer, diabetes or chronic respiratory diseases ) Prevention of extension of communicaoe
by 1/4th of National Family Health Survey-4 (NFHS-4) one unit to another (2) Prevention Labour
levels. (3) Control of drugs (4) Vital statistics (5) social
and poisons and
9. Reduce out-of-pocket spending to 50% of the total welfare (6) Ports other than najor (7) Econo Planning
health expenditure (2014 estimate: 62.4%). planning, and (8) Population control and ran
ily
 HISTORYOF PUBIIC
HEALTH IN INDIA 979
Infant and Young Child Feeding formulated in 9. WHO (1973). Application of Modern
delivery of
Management e ethods and
Health Seruices, SEA/PiA
buidelin
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nues jor the improved
120, WHO, New Delhi.
NIHAE Bulletin, 7,29-55.
o005: (1) RCH II launched (2) Janani
Suraksha Yojana I0.Srivastava, A.B.L. et al (1974).Bulletin, 2 No.1, pp. 29-39.
launched Sharma, H.R. (1969). NIHAE or
(3) National Rural Health Mission 1.
Health Policy-2017, Department
launched health Govt. of India (2017). NationalFamily Weltare, New Deini
standards for Community 12.
Indian Public iealtn (5) India achieved leprosy elimination Health, Ministry of Health and
NIHAE Bulletin, 2. No.3, pp. 5-19. Development
formulated 13. Rao, S.K. (1969).
centres Plan of Action for Health Survey and
TGet by end ot z005 (6) National of India (1946). Report of the
arge tormulated. 4.Govt.
Committee, Govt. of India Press, Simla.
Planning
Children 2005 Survey and
(1962). Report of the Health
(1) WHO releases new paediatric growth chart 15.Govt. of India of Health, New Delhi.
2006 Committee, Ministry on tne
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Special Committee Phase,
the Maintenance
domestic servant (3) RNICP cOvers whole
country since b.
Dreparation for entry of the
NMEP into
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March 2006 (4) National
Family
out
Ministry ot Reorganization of Famity Pianning
Development carved Mukherjee, B. (1966). Report on Services. Ministry ot
61 Ministry of Women and Child 17.
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Kesources and Development eruices,
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16 states. of the Committee on
(6) IMNCI was launched in
18. Govt. of India (1967). Report Health Services, Ministry of
Seruices, Directorate General
(2) NACP III of
Year Plan launched Health
2007 (1) 11th Five Standards for PHC and 1ealth, New Delhi.
launched (3) Indian Public Health of India (1973). Report
of the Committee on Mulipurpose
welrare or
19. Workers under Health and Family Planning Programme,
Govt. Deparnent
sub-centres tormulated (4)
Maintenance and New
passed. Ministry of Health and Famiy Planning.
Citizens Bill 2007 amily Planning,
Parents and Senior of
Non-communicable Disease Programme as Delhi.
Ministry of Health and
Family Planning (1975).
2008 (1) 20. Govt. of India (1975). Support Manpower, New
project launched on 4th Jan. Keport o Group on Medical Education and
pilot

2009 Pandemic Influenza A (H,N,) 2009 outbreak, Delhi.

(1976). Swasth Hind, 20, 233.105-109.
Protection Card came into use. 21. Govt. of India
New ICDS Mother and Child (1976). NIHAE Bulletin,
IX,
All
requirements and 22. Sharad Kumar the Working Group on Health for
announces nutrients India (1981). Report of
2010 lCMR Indians. 23. Govt. of Health and ramily Weltare.
recommended dietary allowances for by 2000 AD, Ministry of Alternative Strategy,
century. ICMR (1980). Health for All An
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census of the 24. ICSSR and

2011 India stages second
Fune.
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RMNCH+A Indian Institute of Education, J. Med.Edu., XI,99.
Mission launched, (1972). Indian
2013 National Health 25. Shrivastav, J.B. NIHAE Bulietin, 5, 179-186.
Dhir, S.L. et al (1972). Fijfth Five Year
launched.
Strategy 26. Commission (1974). Draft
(1) India Newborn Action
Plan launched on 27. Govt. of India, Planningl1, Controller ot Publications, Delhi.
vOI.l&
2014March. (2) India declared polio free country. Plan, 1974-19,
India A Reference
Annual, 1986 Director,
28. Govt. of India (1987).Ministry of Intormation and Broadcasting.
2/th
launched on 25th December. Publications Division, (2012-2017), Social
3) Mission Indradhanush (2014), Twelfth Five Year plan
Yojana Aayog on ist 29. Govt. of India lndia.
NITI Aayog replacesimmunization schedule commission, Govt. of
2015: (1) Sector, vol. ll, Planning 2017-18 to
IPV in Year Action Agenda
danuary 2015; (2) Use of Justice Act 2015; and 30. Niti hreeNew Delhi.
Aayog 2017)of India,
Irom Nov. 2015; (3)
Juvenile 2019-2020, Govt. Statistics in India,
Bulletin on Rural Health
14) Swachh Bharat Abhiyan
launched. officially Govt. of India (2019). Division, Ministry of Health and Family
31.
Development Goals 2018-19, Infrastructure
Sustainable Anganwadi workers Velfare, New Delhi.
2016: (1) Jan. 2016; (2) Malaria eradication ,(1964). Panchayati Raj,
Ministry of Community
ame in to force on 1stemployees; (3) 32. Govt. of India
tOPV to Development, New Delhi.
now government
(2016-2030) launched;
(4) Switch from
and 33. Govt. of Madhya Pradesh, Bhopal (1962). Guide
in Panchayati Kaj, Govt.
Notes, Training of
Central Press,
Pan
bOPV in April 2016.
Officials and Non-officials
certificate Feb. 1961, p. 189.
Aadhar number must for death Bhopal.
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Deniston, O.L. et al (1968).
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rom Oct. 2017; (2) National Scheme; 35. 295.
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36. Tanahasi, (1978).
T.
(1) National (1969). The
2018 of Health and Social Security, Scottish Office
launched. 37.Dept. results achieuved after 1l years.
12) Ayushman Bharat Tuberculosis Fluoridation Studies in the UK and No.22, HMSO,
National Medical Subjects
RNTCP renamed Report on Public iealth and
019
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London.
Brit.Med.J., 1:271.
replaces MCI 38. Sanazaro, PJ. (1974).
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edical Commission"world. on 40. Abramson, J.H. (1979). Survey
2nd ed. Churchill Livingstone.
played havoc in the :3 Management Glossary
SEARO (1984). Health Planning and
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SEARO Reg. Health
Referencesi. ManagementMethods and the
Organization oj
42. Alderson, M.R. and Robin
D. (1979). Health Surveys and
Relate-

1974).Modern paperS Public Health Studies, Pergamon Fress. Efficiency, Nuffiel

Services, Public HealthNationalHealth Planning, Cochrane, A.L. (1972). Effectiveness and
Health APproachesto 43.
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Pan 46. erice O.L. et al (1968). Public Heaith
Reports, 83: 603.
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44. Deniston,
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Oxfo-
NIHAE Bulletin 1, No.2, pp. Knox, E.G.(1979).
narma, H.R. (1968). 261-290. 46.
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d.R: et al (1972). Health, The Publications Divisic-
pta, Rep: Ser., No.350
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(1973). Health Practice
HO
 COMMUNITY Outputs
HEALTH CARE OF THE Health care
984 System
Health care
services
Inputs

Health status or health

problems
Public Changesin
Private health status
Curative
Voluntary
Preventive Indigenous
Promotive

Resources
FIG. 1

system
Model of health care
TABLE 1
Demographic profile
HEALTH PROBLEMS India:
HEALTH STATUS AND 1,400 miliom
problems5 is (2020)
An assesment of the
health status and health Total population 20.0
develop health Crude birth rate (2020)
any planned effort to 6.0
the first requisite for Community Diagnosis.
care services. This is also
known as
and for Crude death rate (2020) 1.2
analyzing the health situation Annual growth rate %
(2020)
The data required for comprise the following: 30 years
defining the health problems Population doubling time
1. Morbidity and mortality
statistics. (at current growth rate) 66.5
of the population. Population rural % (2017)
2. Demographic conditions 74.04
which have a bearing on Adult literacy rate % (2011)
3 Environmental conditions (2020) 464
Density of population per sq.km 899
health. male (2016-18)
factors which have a direct
effect Sex ratio female per 1000 25.9
4 Socio-economic years % (2020)
Population below 15 9.0
on health.
attitudes, beliefs, and Population above 60 years % (2017)
5. Cultural background, 1.8
Average family size (2020)
practices which affect health. 22.3 years
available. Age at marriage, female (2018)
6. Medical and health services Rs. 126,521
Annual per capita GNP
7. Other services available.
in the light of the (at current prices 2018-19)
An analysis of the health situationproblems and health Source: (23, 24)
the health
above data will bring out problems are then ranked
needs of the community. These for allocation of resources. 2. Mortality profile
according to priority or urgency a notable
During the last few decades, there has beenpopulation.
A brief description of current
demographic and mortality
problems of India is given in the improvement in the health status of the 21 (1965) to
profile and the health from
The death rate has steadily declined
following pages. birth has gone up
6.0 (2020). The life expectancy at 67 years
1. Demographic profile considerably since 1951, recording an estimated
2020. The
concern today is population explosion. The for males and 70 years for females during communicable
A major
mortality rates for a number of infectious and
demographic profile is characterised by: registered a decline (e.g., cholera,
diseases have also
a. large population base; tuberculosis, malaria)
rate and family size;
b. high fertility both in terms of birth However, a deeper study reveals distressing situation.
in
C. low or declining
mortality; India's health standards are still low compared to thoseIMK
per cent of the developed countries. While in the world as a whole, the
d. "young" population (about 28 in the
population) below
is the age of l5 years; for the year 2018 is about 29 per 1000 live births, and
developed countries as low as 5, in India it is as high as 32
is close to 34.62
e the proportion of illiterate population has Our life expectancy of about 68 years lags behind by almost
per cent: this explains why the decline in birth rate 12-15 years compared to that in developed countries where
been so slow; and it is currently between 71 and 80 years.
cent for the year 2018;
f. dependency ratio of 50.5 per The current urban death rate (during 2018) was 5.1 and
that is, every economically productive member has to
support almost one dependant. the rural death rate 6.7 per 1000 of population. There wer
as fo
Table 1 summarizes the most recent demographic also considerable interstate variations in death rate, was
information available. example, during 2018 the death rate in Chhattisgarh
 HEALTH STATUS AND HEALTH PHOE
1.09 million cases
wth
2021, India reported
compared to the national average of 19th Feb. Large scale vecena 15
about 8.0.as
abo states, Kerala had the 1,56,111 deaths due to COVID-19.(f) Leprosy eprO5y
hghest, 3.3 in Delhi. Among the going on in the country. Iridia. During the
1000 live births and Madhya Pradesh drive is
health problem
in
and 7 per live births (24) another imporfant public were detected
owest bighest IMR of 48 per 1000
st 2015-2016, total of 1,27,326 new cases deformity grade l
year 9.49% and
e death rate is the highest in the age were are
hadthe
shows that the Out of which child cases 51 48 per cent of these cases
2 result of malnutrition and 4.14%. Union
ears. This is asot atotal and above was multibacillary. All the States and
Table
1aD
group 15 25 per cent
to
deaths are attributed to estimated to be leprosy However, there are
of arnd
ection
and parasitic diseases. lerritories report cases not only between one State
Considerable variations With the
intectio
TABLE 2 between one district and another. inidia
another, but also population,
Child (Under 5 years) and
infant mortality 0.68 per 10,000
prevalence rate of aboutleprosy elimination at national level.
indicators, India 2018 the goal of endemic in about
Urban
hasachieved: The problem of filaría remains popuiation at risk 15
Indicators Total Rural 9) Filaria States and 5 UTs. The of
36 40 26 255 districts ín 16
To achieve elimination of LF the Govt Drug
mortality rate Over 630 million. Mass
23 nationwide Annual
Child
mortality rate
32 36
India has launched with annual single recommended
Infant 23 27 14 Administration (MDA) addition to
Neo-natal mortality rate 20 10 diethylcar-bamazine citrate tablets in operations.
care and hydrocele
mortality rate 18 dose of
Early neo-natal
mortality rate 5 3 scaling up home based foot implernented MDA targeting a
districts of 87
In 2014, 250 endemic
neo-natal
Late
mortality rate 9 9
554 million with a coverage rate It is
neo-natal 14 population of about stable.
: The problem of AIDS is
Post 22 25
Peri-natal mortality rate 4 per cent. (h) AIDS end of year 2017 there were about
2.1
rate by the : Kala-
Still birth estimated that country. (i) Others
HIV positive cases in the encephalitis.
Source: (23) million hepatitis, Japaneseinfestations are
azar, meningitis, viral and helminthic
2
Health problems dengue fever, enteric fever communicable disease problems
may be conveniently other important can be
The HEALTH
PROBLEMS of India among the
tragedy is that most of these diseasesinput of
heads: in India. The treated with minimum
grouped under the following
problems; either easily prevented or developed countries of the
1. Communicable
disease resources. In fact most of the by such
Non-communicable disease problems; overcome many of these problems
world have practice of
2.
problems; as manipulation of environment, living.
3 Nutritional measures improvement of standards of
04 problems medicine and
4. Environmental sanitation preventive
Non-communicable diseases (NCDs) transition
154

5. Medical care problems;

and
9 2.
. 6. Population problems.
problems
India is experiencing a
rapid epidemiological
rising burden of chronic
diseases, whici
1. Communicable disease with a large and per cent of all deaths
i

problem to account for 63 cance

be a major were estimated mellitus, CVDs,
13 Communicable diseases continue to importance today 2016. NCDs, especially diabetes majc
in India. Diseases considered
to be of great
major health and chronic lung diseases have emerged as an
continues to be a stroke, to an ageing population
are: (a) Malaria: Malaria malaria cases has declined public health problems due
problem in India. Although total
proportion of P falciparum environmentally-driven changes in behaviour.
compared to previous years, the health proble
Malaria cases have increased in North-East Cancer has become an important public cases occurri
has increased.
Chhattisgarh, Jharkhand, Orissa, 1.1 million lakh
states, Madhya Pradesh, were in India with an estimated it is estimated that there
a

Maharashtra etc. During 2019 there every year. At any point of time,
Andhra Pradesh,
(which included 46.36%
cases country. In India, tobac
ble
0.34 million cases of malaria nearly 3.9 million cases in the total canc
deaths. (b) Tuberculosis related cancers account for about half the one mill
of Pf malaria) and 73 India women. About
to luberculosis remains a public
health problem, with among men and 20% among toba-
UP
of the world incidence. Every year
tobacco related deaths occur each year, making
accounting for one-fifth concern. In In=
persons develop tuberculosis, of which related health issues a major public health
about 2.2 million infectious blind. Cataract (62.6
The
about 0.62 million are
new smear positive highly
every year. more then 12 million people are followed by Refrac
able
million people die of
1TB
cent) is the main cause of blindness
Cases and about 0.24 and multidrug been a signiticant incr=
eid The emergence of
HIV-TB co-infection Error (19.70 per cent). There has
severity and magnitude of the with Intra Ocular
resistant TB has increased the nation-wide in proportion of cataract surgeries
RNTCP has achieved (IOL) implantation from <5 per cent in 1994 to 95 per
disease. In March 2006 : Diarrhoeal diseases not been given suffi-
coverage. (c) Diarrhoeal diseases in 2016-17. Oral Health Care has
causes of morbidity and hospitals
constitute one of the major They are importance in our country. Most of the district
5 years of age. surgeon but they lack equipr
mortality, specially in children below diarrhoea each a post of dental
million cases of machinery, and material. Even where the equipment e
responsible for about 13.19 (including cholera) is affea
year. Outbreaks of diarrhoeal diseases environmental the maintenance is poor, hence service delivery
Continue to occur in India due to poor
Conditions. (d) ARI: Acute repiratory
diseases are one of the 3. Nutritional problems
morbidity in children below 5
major causes of mortality and episodes of ARI From the nutritional point of view, the Indian socie
41.996 million
years of age, During 2018,
India haad dual society, consisting of a small group of well fed
were reported with 3,740 deaths. (e) COVID-19: very large group of undernourished. The high
during the pandemic, as of
tS share of COVID-19 cases

63
 RESOURCES 987
lation: and (i) desired outputs. The health needs in as tuberculosis control, leprosy eradication and control of
poro
urn based on the health situation and health problems blindness needed more trained workers and technicians.
and aspirations of the people. Thus during the pasl decade many new categories of healfh
Health manpower planning is an important aspect of manpower have been introduced. They include village
rmmunity health plannin9. It is based on a series of health guides, multipurpose workers, technicians,
accepted ratios such as doctor-population ratio, nurse- ophthalmic assistants, etc. Table 5 gives the total health
nopulation ratio, bed-population ratio, etc. They are given in manpower current stock under the "rural health scherne"
Table 3. The country is producing annually, on an average
TABLE 5
31.298 allopathic doctors, 9,865 Ayurvedic graduates;
1525 Unani graduates; 320 Siddha graduates and Health man-power in rural India as on Marcli 2019
12785 Homoeopathic graduates (26). Category In posltion
TABLE 3 ANM at sub-centre and PHC 2:34,220
1.
59,348
Suggested norms for health personnel 2. MPW (Male)
8. Health Assistant (Female)/ LHV 13,786
Category of personnel Norms suggested 4. Health Assistant (Male) 13,446
Nursing staff at PHC and CHC 80,976
1. Nurses 1per 5,000 population 5.
6. Doctors in PHCs 29,799
2. Health worker 1 per 5,000 population in plain
female and male area and 3,000 population 7. General duty medical officers allopathic
in tribal and hilly areas. at CHC 15,395
3. Trained dai One for each village Specialists
4. Health assistant, 1 per 30,000 population in plain
(a) Surgeon 768
(male and female) area and 20,000 population 1,351
in tribal and hilly areas. (b) Gynaecologist and Obstetrician
Provides supportive super (c) Physician 683
vision to 6 health workers (d) Paediatrician 1,079
(male / female).
Total Specialists at CHC 3,881
5. Pharmacists 1 per 10,000 population
Radiographer 2,419
6. Lab. technicians 1 per 10,000 population
10. Pharmacist 26,204
7. ASHA 1 per 1,000 population
11. Lab. Technician 18,715
Source:(27) 12. BEE 3, 7
Although the averages are satisfactory on a national
Source:(41)
basis, they vary widely within the country. There is also
maldistribution of health manpower between rural and Money and material
urban areas. Studies in India have shown that there iss a
concentration of doctors (upto 73.6 per cent) in urban areas Money is an important resource for providing health
where only 26.4 per cent of population live. This services. Scarcity of money affects all parts of the health
maldistribution is attributed to absence of amenities in rural delivery system. In most developed countries, average
areas, lack of job satisfaction, professional isolation, lack of government expenditure for health is about 18 per cent of
rural experience and inability to adjust to rural life. GNP. In developing countries it is less than 1 per cent of the
GNP and it seldom exceeds 2 per cent of the GNP. This
The national averages of doctor-population ratio, translates into an average of a few dollars per person per
population-bed ratio and nurse to doctor ratio in some year in the underdeveloped countries as compared to
countries are shown in Table 4. several hundred dollars in developed ones. To make matters
TABLE 4 worse, much of the spending is for services that reach only a
small fraction of the population.
Health manpower in some countries 2010-2018
To achieve Health for All, WHO has set as a goal the
Doctors Beds Nurses and Midwives
per 10000 per 10000 per 10000 population expenditure of 5 per cent of each country's GNP on health
Country care. At present India is spending about 3 per cent of GNP
population population
on health and family welfare development.
India 7.8 7.0 20.9o Since money and material are always scarce resources
Bangladesh 8.0 2.2
5.6 they must be put to the most effective use, with an eye on
Sri Lanka 9.6 36.0 16.4 maximum output of results for investment. Since deaths
Thalland 8.1 21.0 20.8 from preventable diseases such as whooping cough,
Myanmar 8.6 9.0 10.0 measles, tuberculosis, tetanus, diphtheria, malnutrition
frequently occur in developing countries, the case is strong
Source: (25) for investing resources on preventing these diseases rather
than spending money on multiplying prestigious medical
Health manpower requirements are subject to change,
institutions and other establishments which absorb a large
both qualitatively and quantitatively, as new programmes,
care portion of the national health budget (30). Management
projects and philosophies are introduced into the health
system. For example, there has been a change from techniques such as cost-effectiveness and cost-benefit
unipurpose to multipurpose strategy. Then came the goal of analysis are now being used for allocation of resources in the
Health for All. In addition, national health programmes such field of community health.
1000 HEALTH CARE OF THE COMMUNITY

counselling and services related to sexual concerns, Support manpower:

pregnancy, contraception, abortion, menstrual
problems etc. Personnel Strength
Services for tetanus immunization of adolescents. Staff Nurse 19**
Nutritional counselling, prevention and management Public Health Nurse (PHN)
of nutritional anaemia. ANM
Pharmacist/compounder
STI/RTI management Pharmacist-AYUSH
Referral services for VCTC and PPTCT services and Lab. Technician
services for safe termination of pregnancy, it not Radiographer
available at PHC. Ophthalmic Assistant
Dresser (certified by Red Cross/ 2
11. Blood storage facility. St. Johns Ambulance)
12. Diagnostic services: (a) In addition to the lab Ward Boys/Nursing Orderly
facilities and X-ray, ECG should be made available in Sweepers
the CHC with appropriate training to a nursing
staff Chowkidar
Lab/ Technician; and (b) AIl necessary reagents, glass Dhobi
ware and facilities for collecting and transport of Mali
samples should be made available. Aya
Peon
13. Referral (transport) services.
OPD Attendant
14. Maternal Death Review (MDR). Registration Clerk
Statistical Assistant/Data Entry Operator Z
Manpower for community health centres Accountant/Admin. Assistant
In order to provide round the clock clinical OT Technician
services, the
revised IPHS staff pattern is as follows (37) Total 64
*Will be appointed under the ASHA scheme.
|Personnel Strength Desirable Qualifications ** For
providing round the clock service at OT, labour room, casualty,
Block Health Senior most specialists among male ward and female ward along with provision of leave reserve.
Officer the below mentioned
speciality (Physician/General 5. HEALTH AND WELLNESS CENTRES (41)
surgeon/Paed./Obs & Gyne The National Health Policy, 2017 recommended
Anaesthesia/Public Health/ strengthening the delivery system of primary health care,
Ophthalmology) through establishment of "Health and Wellness Centres
General Surgeon 1 MS/DNB, (General Surgery) (HWCs)" as the platform to deliver comprehensive primary
Physician MD/DNB, (General Medicine) health care. Government of India is committed towards
creation of 1,50,000 Health & Wellnes Centres (HWCs) by
Obstetrician & MD/DNB/DGO (OBG) transforming existing Sub-centres (SCs) and Primary Health
Gynaecologist Centres (PHCs) as basic pillars of Ayushman Bharat to
Paediatrics MD (Paediatrics)/DNB/DCH deliver Comprehensive Primary Health Care (CPHC)
These centres deliver CPHC bringing healthcare closer to
Anaesthetist MD (Anaesthesia)/DNB/DA/ the homes of people, covering both maternal and child
Certificate course in health services and non-communicable diseases, including
Anaesthesia for one year free essential drugs and diagnostic services. The emphasis ot
Public Health 1 MD (PSM)/MD (CHAJMD health promotion and prevention is designed to bring focus
Manager Community Medicine or Post on keeping people healthy by engaging and empowering9
Graduation Degree with MBA individuals and communities to choose healthy behaviours
and make changes that reduce the risk of developing chronic
Eye surgeon MD/MS/DOMS/DNB/
(1 for
diseases and morbidities.
(Ophthal)
every five To ensure delivery of CPHC services, existing SCs
CHCs) covering a population of 3000-5000 would be converted to
HWCs, with the principle being "time to care" to be no more
Dental Surgeon 1 BDS than 30 minutes. PHCs in rural and urban areas would alis0
General Duty6 MBBS be converted to' HWC. Such care could also be provided
Medical Officer (at least complemented through outreach services, mobile medical
2 female units, camps, home and community-based care, but the
doctors) principle should be a seamless continuum of care that
Specialist of 1 Post Graduate in AYUSH ensures the principles of equity, universality and no financial
AYUSH hardship.
General Duty 1 Graduate in AYUSH SC-HWC team
Medical Offier
of AYUSH The HWC at the SC level would be equipped and stafted
Total by an appropriately trained primary health care team.
15/16 comprising of multi-purpose workers (male and female) *
 JOB DESCRIPTION OF MEMBE5 OF THEMEALTHH TEAA 1001
the afternoon
4SHAs, and led by a
Mid-Level Health Provider (MLHP). allending to patients in the out-door; in
de an expanded range of services. In
Togethei they will deliver he supervises the field work.
have earlier been upgraded to additional as to cover all the
ome states, SCs 2. His tour programme is so designed
additional PHCS will also be transformed to family planning.
PHCS. Such basic health services including
guidelines and
HWCS. 3. He will plan and implement UIP as per population
PHC that is linked to a cluster of HWCs would serve as ensure maximum possible coverage of the of vaccine
h
point of reterral tor many disease conditions for the in the PHC. He will ensure proper
storage
first
jurisdiction. In addition, it would also be chain equipment. He will
uWCs in its and maintenance of cold
trengthene0
ed as a HWC to deliver the expanded range of ensure adequate supplies of vaccine and miscellaneous
implementation of OIP
primary care services. items required for the effective
4. He will ensure proper
implementation of IMNCI as per
PHCIUPHC-HWC team
guidelines.
The Medical Officer at the
PHC would be responsible for PHC area at regular
5. He will visit schools in the
ensuring that CPHC services are delivered
through all HWCs medical check up and
PHC itself. The number and intervals and arrange for
in her/his area
and through the immunization.
oualifications of staff at the PHC would continue as defined conduct tubectomy and
Health Standards (IPHS). 6. He will organize and
in the Indian Public vasectomy camps.
personnel like ASHA,
Expanded services 7. Organize training of all heath
of services. anganwadi worker, Dais etc.
The HWC would deliver an expanded range programmes are being
These services would be delivered at both Sub-centre and in 8. He ensures that national health
transformed as HWCs. The level of implemented in his area properly.
the PHCs. which are
complexity of care of services delivered at the PHC would be regularly on fixed days and
9. He visits each subcentre
higher than at the Sub-centre level and
this would be guidance, supervision and
treatment hours and provides
indicated in the care pathways and standard leadership to the health team.
guidelines.
10. He spends one day in each
month organising staff
to discuss the
The expanded range of services are as
follows: meetings at ihe primary health centre activities
problems and review the progress of health
1. Care in pregnancy and child-birth.
health centre depends
2. Neonatal and infant health care services. 11.The success of a primary which the medical
care services. largely on the team leadership
3. Childhood and adolescent health officer is able to provide. The
medical officer must be
contraceptive services and other director, the supervisor,
4. Family panning, the planner, the promoter, the
reproductive health care services. the coordinator as well as the evaluator.
5. Management of
communicable diseases including
national health programmes. Second Medical Officer
identical duties.
6. Management of common
communicable diseases and The second medical officer performs
illnesses and minor
out-patient care for acute simple 2. Health worker Male and Female
ailments. one health
management of non- Under The Multipurpose Worker Scheme,are posted at
1. Screening, prevention, control and
communicable diseases. worker female and one health worker male population of
cover a
ENT problems. each sub-centre and are expected to However, health
8. Care for common ophthalmic and 5000 (3000 in tribal and hilly areas).
350-500 families.
9. Basic oral health care. worker female limits her activities among
10.Elderly and palliative health care services. A. HEALTH WORKER FEMALE (ANM)
11. Emergency medical services.
of mental health She will carry out the following functions:
12.Screening and basic management
1. Maternal and Child Health
ailments.
1.1 Register and provide care to pregnant women
centre was inaugurated by
The first health and wellness throughout the period of pregnancy.
April 2018 at at Bijapur,
the Prime Minister on 14th 1.2 Ensure that every pregnant woman makes at
there were 17,895
Chhattisgarh. As on 31st March 2019, least 4 (lour) visits for antenatal check-up
7,821 are HWC-SCs
HWCs, functional in India. Out of these
HWC-PHCs (rural) and according to suggested schedule.
rural); 98 HWC-SCs (urban); 8,242 (41).
1,734 HWC-PHCs (urban) are functional 1.3 Test urine of pregnant women for albumin and
sugar, Estimate haemoglobin level.
MEMBERS OF 1.4 Refer all pregnant women to PHC for RPR test
JOB DESCRIPTION OF
THE HEALTH TEAM for syphilis.
1.5 Refer cases of abnormal pregnancy and cases
1. Medical Officer, PHC with medical and gynaecological problems to
primary Health Assistant Female (LHV) or the Primary
L. He is the captain of the health team at the
morninghours Health Centre.
healthcentre. He devotes the