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EPIDEMIOLOGY
Definitions and Concepts

EpidEmiology

Epidemiology > Among People study

Definition → Study of Diseases in a population

Distribution Determinants AND Frequency

Time Perspm Cause Incidence Prevalence

Place Most Important

Defined by John M. Last

distribution of diSEASE
A. Time/Seasonal distribution
Season Vector
1. Malaria → Rainy → Anopheles culicifacies (Rural) & stephensi (URBAN)
2. Dengue → Rainy → Aedes aegypti [Tiger Mosquito]
3. Typhoid Rainy
4. Cholera Rainy
5. Polio Rainy
6. Rotaviral Winter

Respiratory infections
1. Polio Rainy
2. Measles Winter
3. Mumps Winter
4. Rubella Winter
5. Chicken pox Winter The Droplet Size that transmits most efficiently → < 5 µ
6. H1N1 Winter Inter Personal distance where transmission is max → < 1 meter
7. Diphtheria Winter
8. Pertussis Winter
9. DM None
10. HTN No None
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11. CHD Disease None

12. Cancers None
13. RTA Winter, Rainy
14. HIV None
15. Hay Fever Spring, winter [Pollen, Dust]
16. Asthma → Winter
17. Covid-19 None

B. place distribution (geographical distribution)

place Vector
1. Kala azar UP, WB, Bihar, Jharkhand Phlebotomus [Sand Fly]
2. Japanese Encephalitis UP, WB - Culex Triteniorhyncus
- C. vishnuii
- C. Gelidus
3. KFD Kyasanur Forest [Karnataka] Hard Tick
[Hem physalis spinigera]
4. Malaria East & North East India Anopheles
5. Filariasis Coastal Region of India Culexquinque fasciatus
[C. fatigues]
6. Fluorosis Central & western India

7. HIV High Prevalence states [7]

Tamil Nadu, Karnataka, Andhra
Pradesh Maharashtra Nagaland, Mani-
pur, Mizoram,
Moderate Prevalence state [3]
Gujarat, Goa, Pondicherry
Low Prevalence States
All Other parts of India
8. Measle Mumps Rubella No place distribution
C. pox
9. Covid-19 Kerala, Maharashtra
10. Polio, Yellow Fever Do not occur in India

New diseases
india [Emerging/Re-emerging]
1. H1N1 [swine flu] Metros
2. Congo fever Gujarat, Delhi Hyalomma, Hard ticks
3. Litchi Virus Disease West Bengal d/t MCPG
4. Ebola Virus Delhi d/t body fluids
5. Zika Virus Gujarat, Tamil Nadu, Aedes
6. Plasmodium Ovale Gujarat, WB Delhi, Mumbai
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Definitions and Concepts

7. NIPAH Virus WB, Kerala Fruits with Bat secretions

8. West Nile Fever Kerala
9. Covid-19 (March 2020)
10. H5NI (July 2021)
11. Monkey Pox (July 2022)

New diseases World

1. H1N1 Mexico, South Asia
2. H5N1 [Bird Flu] Hong Kong, South Asia
3. H7N9 China [2013]
4. MERS [Middle East Resp. Syn.] Middle East Countries MERS by COV corona virus
5. Ebola Africa
6. Zika Africa
7. Covid-19 China MERS COV- Coronavirus 2
8. H10N3 China (June 2021)

C. person distribution (As per age or sex)

C1. Age distribution
Measles → 6 months - 3 Yrs
Mumps → 5-9 yrs [school going Age]
Chicken Pox → 5-9 yrs [school going Age]
H1N1 → No Age Distribution
Rheumatic fever → 5-15 yrs
Rota Virus → Younger Infants
Neonatal Tetanus → Neonates
Polio → 0-5 yrs
DM → > 40 yrs
HTN → > 40 yrs
CHD → > 40 yrs
Cancers → > 50 yrs
Cataracts → > 50 yrs
Typhoid / Cholera / Covid-19 → No age distribution

Age groups
Neonates → 0-28 days
Infant → 0-1 years
Toddler → 1-3 years
Child → 0-18 Yrs
Adolescent → 10-19 yrs
10-13 yrs [early]
14-16 yrs [mid]
17-19 yrs [late]
Reproductive Age Group → 15-49 Yrs
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Geriatrics → > 60 Yrs

Perinatal Period → 28 weeks POG till 7 days’ post delivery
Period of viability → POG > 28 Wks OR BW > 1000gms (or) BL > 35cm
Abortion → POG < 28 WKS OR BW < 1000 gms (or) BL < 35 cm
Still Birth → POG > 28 WKS OR BW > 1000 gms (or) BL > 35 cm
BW is most sensitive criteria for POV

C2. Sex distribution

Measles
Mumps
Rubella No sex Distribution
Chicken Pox
Covid-19

H1N1 → No Sex Distribution

Malaria → No Sex Distribution
Dengue → No Sex Distribution
DM → Males
HTN → Females [as they have higher Life expectancy]
CHD → Males

Polio
Typhoid No Sex Distribution
Cholera

HIV → Females [ 7-10 times more chance of having infection]

RTA → Males

Cancers
Breast → Females
Cervical → No sex distribution [only seen in females- sex restricted]
Oral → Males
Lung → Males
Cataract → Females [higher life expectancy]
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Epidemiological Studies- Cohort Study, Case

Control Study

EPIDEMIOLOGICAL STUDIES CLASSIFICATION

OBSERVATIONAL INTERVENTIONAL

Descriptive ANALYTICAL EXPERIMENTAL

Hypothesis formulation Hypothesis Testing Hypothesis Confirmation

Done In Done by Done by

1. Time I. Cohort study a. RCT
2. Place II. Case control study b. Clinical Trial
3. Person III. Cross sectional study c. Field Trial
IV. Ecological study d. Community Trial

COHORT STUDY CASE CONTROL STUDY

→ Forward → Backward
→ Prospective → Retrospective

100 smokers → Lung cancer Smoking ← 100 Lung cancer

2023 2038 2008 2023
History

Cause → Effect Cause ← Effect

Exposure → Outcome Exposure ← Outcome
Risk Factor → Disease Risk Factor ← Disease
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Cohort Study
Exposed Non-Exposed
→ 2023 100 smokers →100 Nonsmokers
↓ ↓
→2038 80 Lung smokers 10 Lung cancers
Golden rule of epidemiology → Always take comparison groups

→ Take 2 groups→Exposed & We wait for occurrence

Non-Exposed of same disease in both
groups & then compare
→Results calculated by → Strength of Association

Strength OF Association is given by

1. Relative Risk (RR)

2. Attributable Risk (AR)

3. Population Attributable Risk (PAR)

a Relative Risk

RR → le/Ine (Ie→ Incidence in exposed, Ine→ Incidence in non-exposed)

RR = (80 / 100)/ (10/100) = 8

→ Implies, smokers are relatively 8 times higher risk of lung cancer as compared to Non-smokers
→ RR = Risk Ratio → Ratio of developing lung cancer b/w smokers and Non smokers→ 8:1

→ RR >1 → Association present

RR = 1 → No Association
RR < 1 → Negative/Inverse Association→Risk factor is protective (beneficial)

b Attributable Risk [AR] / Excess Risk / Absolute Risk / Risk Difference

# le " ln e $
AR ! % 100
le
#80 / 100
"10 /100 $
AR ! % 100 ! 88%
AR= [(80/100)-(10/100)]
80 / 100/ (80/100) x 100 = 88%
Interpretation → 88% of Lung cancer can be attributed to smoking
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Epidemiological Studies- Cohort Study, Case Control
Vitamin
Study
A

c Popular Attribution Risk [PAR]

ITOTLE " I NE
PAR ! X 100
ITOTLE
# 90 / 200 " 10 / 100 $
PAR ! X 100 ! 77%
90 / 200

Interpretation :
If smoking is eliminated from the same population then there will be a 77% reduction of new cases/ Incidence
of lung cancer every year in the same population

Fig 1. Cohort Study

Use of RR, AR, PAR in Public Health:

1. Clinician →Relative Risk

2. Epidemiologist →Attributable Risk

3. PH Programme Manager → Population Attributable Risk

COHORT STUDY (Synonyms)

→ FORWARD LOOKING STUDY
→ PROSPECTIVE STUDY
→ CAUSE TO EFFECT STUDY
→ RISK FACTOR TO DISEASE STUDY
→ EXPOSURE TO OUTCOME STUDY
→ FOLLOW UP STUDY
→ INCIDENCE STUDY
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FRAMINGHAM HEART STUDY

→ Most popular cohort study

→ For CAD [coronary artery Disease] in 1948, USA
→ Made a list of Risk factors
→ Age group → 30-62 yrs
→ Sample size → 4469 → Divided in to exposed & non exposed groups
→ Checking of Incidence of CHD every 2 yrs
→ Framingham → Town in USA
→ Type of COHORT Study

• Cohort defined as Group of Individuals having same characteristic

• Minimum no. of cohorts required in a cohort study → O2

CASE CONTROL STUDY

2008 → 70 smokers 10 Smokers

↑History ↑History

2023 → 100 Lung cancers 100 Healthy People

[Diseased] [Non-Diseased]

↑ ↑

Cases Controls

and ask history of same exposure

Cases in both the groups
Take 2 groups
Controls & then compare

Strength of Association → Given by ODDS Ratio/Cross Product Ratio

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Epidemiological Studies- Cohort Study, Case Control
Vitamin
Study
A

Interpretation
OR> 1 → Association Present
OR =1 → No Association
OR< 1 → Inverse/Negative Association → RF is protective(beneficial)
Lung cancer cases have 21 times more chance of reporting History of smoking as compared to healthy people
in the study

Case Control Study (Synonyms)

→ Backward looking study
→ Retrospective study

→ Effect to cause study

→ Disease to Risk factor study
→ Outcome to exposure study
→ TROHOC study
→ Case reference study

case control
→ Ideal Ratio for Good case control study→ 1 : 4
Minimum ratio for case control study→ 1 : 1

Advantages & Disadvantages: (Cohort VS Case Control Study)

COHORT STUDY CASE CONTROL STUDY

D →Time consuming study A →Quicker study

D →Expensive study A →Cheaper study

A →Incidence, RR [more accurate] D →Odds Ratio

A →No Recall Bias D →Recall Bias +nt

D →Loss to follow up [Attrition]

• Max allowable attrition Rate <5% A→No loss to follow up
• Ideal retention rate >> 95%

A →Multiple Outcomes can be studied together A →Multiple Risk factors can be studied together.

D →HAWTHORNE BIAS - Study subjects A→No Hawthorne Bias

alter their Behavior without notice

D → Ethical Problems present A →No Ethical problems

D→Not useful for rare diseases A →Useful for rare diseases

Cohort study is better study than case control study → b/c → most accurate
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Combined Designs & Other Studies

COMBINED DESIGNS
PROSPECTIVE Cohort study Retrospective Cohort Study Case control study
Smoking 2023 → lung ca 2038 Combination of both Smoking 2008 ← lung ca 2023
smoker 2008 → Lung CA 2023
Incidence RR Incidence RR saves time ODD’S Ratio

Fig. 1: Case Control Study

Mixed Cohort Study

→ Combination of both retrospective & prospective cohort study

RC PC
Smokers 2008 Lung CA 2023 Lung CA 2033

NESTED CASE CONTROL STUDY

→ Type of cohort study
→ Temporality → forward looking study
→ Only done if
1. Disease New & Rate
2. Diagnostic tests very expensive
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→ E.g. → Stem cell Banking

Fig. 2: NCC Study

Fig. 3: NCC Study

→ A Nested case control study is a small case control study which is nested in a big cohort study

Present “At The Start” of Cohort Study

EXPOSURE OUTCOME
1. PROSPECTIVE Cohort STUDY ✓ X

2. CASE CONTROL STUDY ✓ ✓

3. RETROSPECTIVE Cohort STUDY ✓ ✓

4. MIXED Cohort STUDY ✓ ✓→✓

5. NESTED CASE CONTROL STUDY ✓ X

Retrospective cohort study > Prospective cohort study > Case control study
Incidence relative risk saves time Incidence relative risk Odds ratio
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Combined Designs & Other Studies

OTHER ANALYTICAL STUDIES

Cross Sectional Study / Snapshot Study / Prevalence Study
• Done at a point time, neither forward or backward in direction
• E.g. 2023
– Smokers → 40%
– Lung CA → 01%
• Can’t calculate strength of association (incidence, OR, RR)
• Gives Prevalence
• Based on primary date [Investigator collects data himself]

ECOLOGICAL STUDY / CO-RELATIONAL STUDY

• Done at a point of time [E,g. in 2023]
• Used in Nutritional surveys
– E.g. → Avg. fat intake = 20gm/day
• Can’t calculate strength of Association or Prevalence
• Based on secondary data [collected by someone else, studied by investigator]

RCT > RCS > PCS > CC > CS > E

Unit of Study
• Results of study Applicable on

• Cohort
• Case control Individual E → Population
• Cross sectional RCT → Patient / Case
Descriptive → population
Ecological fallacy (E. study results are not applicable on Individuals in the study)
• All analytical studies have individual as unit of study except Ecological

Must Know
• Cohort study, Case control study and their Combined study designs are Horizontal studies (having a
direction)
• Cross Sectional study, Ecological study are Vertical studies (having no direction)
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Confounding & Bias

CONFOUNDING = Error

→ Any factor associated both with exposure & outcome

↓leads to
Mistaken estimate of outcome
Example
→ Smoking [Exposure] Leads to Lung CA [outcome]. Factors associated with both smoking and lung cancer (for
example old age, male sex) will lead to mistaken estimate of outcome. This is known as confounding.
→ Confounding can be removed by MATCHING

• Equal distribution of confounding factors in both the groups

Confounding can be removed by

1. Matching → MC used /simplest

2. Randomisation → 2nd Best Method
3. Restriction
4. Stratification
5. Statistical Modelling / Multivariate analysis (MVA)
6. Stratified Randomization→ Overall Best Method

• Confounding factor: Any factor associated with both exposure and outcome, and
has an independent effect in causation of outcome is a confounder
○ It is found unequally distributed between the study and control groups
• Mediator: Third variable (mediator, M) carries the influence of a given risk factor
to a given disease/outcome
○ Mediator comes in between the risk factor – disease continuum
• Effect modifier (Interactor): Third variable (Effect modifier) whose level
determines the magnitude of effect in a study
○ It modifies Strength of association between exposure and outcome
• Collinearity: Two independent factors are so highly correlated that it becomes
difficult to distinguish their individual effect on disease/outcome
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Bias:

→ Type of Systematic error

→ 3 Types
1. Subject Bias ·

• RECALL BIAS (CASE control study)

• HAWTHORNE BIAS [cohort study]

2. Investigator Bias

• Interviewer BIAS → ELIMINATED by devoting EQUAL time to cases and controls

• Selection BIAS

• MISCLASSFICATION BIAS

3. ANALYSER BIAS CALCULATION ERROE – Not Seen Now-a-days

OTHER TYPE OF BIASES

BERKESONIAN BIAS → d/t different hospital admission rates

→ Based on location & reputation of an institute → Type of Investigator (selection) bias

Pygmalion Bias

→ Motivation by teacher, can increase the marks of students

→ Type of Investigator [3rd person] Bias→Selection Bias

GOLEM BIAS

→ Demotivation by teacher can decrease marks of students.

→ Apprehension bias: Certain levels (pulse, blood pressure) may alter systematically
from their usual levels when the subject is apprehensive
→ Attention bias (Hawthorne effect): Study subjects may systematically alter their
behaviour when they know they are being observed
→ Lead time bias (Zero time shift bias): Bias of over-estimation of survival time, due
to backward shift in starting point, as by screening procedures
→ Neyman bias (Prevalence-incidence bias): Bias in case load estimation due to
missing of fatal cases, mild/silent cases and cases of short duration of episodes from
the study
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Confounding
Vitamin
& Bias
A

Types of blinding
Single Blinding → Subjects are not aware of Rx (used to remove subject Bias)

Double Blinding → Subject & investigator both not aware of treatment Removes subject &
Investigator Bias (Most common type of Blinding seen)

Triple Blinding → Subject, Investigator & Analyzer not aware of treatment Removes
subjects, Investigator &Analyzer Bias (Best Blinding)

Open Study → Complete absence of Blinding

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RCT, Trials

• A New Antipyretic drug - M

• Unit of study - Patient / Cases
RCT

100 pt 100 pt
Experimental Group Reference Group
Intervention Given No Intervention

I. M Drug given I. No Drug given

80% Reduction of fever 10% Reduction of fever
20% people may take PCM → Subject on their own Bias

Hawthorne Bias
II. M Drug Given II. Placebo given
Single Blinding
80% Reduction of fever 10% Reduction of fever

III. M Drug given III. Old Drug [PCM]

1 Death occurs

Drop Out Cross Over

• ITT [Intention to Treat Trial] • Results of RCT are not affected by death, dropout, crossover

Selection Bias is an Investigator Bias

Selection Bias in RCT removed by Randomization

MCQ. Randomization Applied

1. At selection of 200 pts
2. At distribution into EG & RG (Best time for Randomization)
3. At Medication
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4. At comparison of Results
Randomization Remove Selection Bias
Remove Confounding
Matching removes Confounding
Blinding removes Bias
RCT > RCS > PCS > CC > CS > E

Types of Randomized Trials

1. Clinical Trials
2. Preventive Trials
3. Risk factor Trials
4. Cessation Experiments
5. Trials of etiological agents
6. Evaluation of health services

Types of Non Randomized trials

1. Uncontrolled Trials
2. Natural Experiment
3. Before & After comparison studies

Clinical Trials
Phase I Healthy Human Volunteers
Done for safety & Non-toxicity
Maximum Tolerated dose (MTD) tested
Phase II Patients
Done for Efficacy
Maximum drug failure is seen
Phase III Patients
Comparison with existing drug
New Drug launched in market after phase III
RCT done
Most important phase
Phase IV Patients
Done for long term side effects
Post Marketing Surveillance
Longest - Time period
Lifelong [ideal] or 10-25 Years

Phase O Few Healthy Human Volunteers

For micro dosing [e.g. 1/10th dose]

Pre-clinical Trials done in Animals (before clinical Trials)

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EBM, Meta Analysis, Other Studies

Meta-analysis
• Analysis of Analyses
Analysis of Multiple studies together
• E.g. 96 studies → Single Result
• Meta-Analysis > RCT > RCS > PCS > CC > CS > E

Study 1 Study 2 Study 3 Study 4

Combined
Meta-Analysis
Results

Fig.1: Meta-analysis
• It is a type of objective systemic review that employ statical methods to combine & summarise results
of multiple studies.
• Meta-analysis is defined in a very unique way that is “Analysis of Analyses”
• Analysis of multiple studies together
• It is top of EBM pyramid
• It is considered to be the best study design to be undertaken in epidemiology.
E.g. If a researcher wants to do Meta-analysis of smoking and lung cancer, He has to collect all published and
unpublished studies on smoking, lung cancer (cohort studies) in the world till now and try to synthesize them
into a single result Quantitatively
• Results of multiple studies is better than an isolated cohort study

MA
Sys. Review
RCT
RC > PC
CC
CS > E
Opinion, views
Animal Research
In Vitro Research

Fig.2: eBM Pyramid

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aims of Meta-analysis
• It leads to estimate of Magnitude of effect
• It increases the precision of all studies together. It increases the power of the studies
• Top of EBM Pyramid-Meta-Analysis
• Gold std for EBM-Meta-Analysis
To summarise in simple words when you have multiple studies you combine the results quantitatively and do a
synthesis study this study design is known as meta-analysis

1. Forest Plot
• In a forest plot multiple studies could be depicted in a parameter of strength of association like odds ratio
on a single graph with the study result & along with their confidence interval also this way the researcher
can compare the studies with each other and also he can calculate the summary measure known as Diamond

2. Funnel Plot
• It tells you whether there is systematic bias or heterogeneity especially publication bias if it is present
in Meta-analysis

Strengths of Meta-Analysis
• It provides point estimate of “Effect size”
• It also helps us report confidence Interval around the effect size (this will help us decide whether
the confidence interval includes 1 which is the line of null or whether the results are significant or
insignificant or conclusive or in conclusive)

Limitations of Meta-analysis
• Garbage in Garbage Out (GIGO)
• Apples & oranges effect
• File Drawer effect / Publication Bias
• Meta-analysis relies on shared subjectivity

Difference between Meta-analysis and Systematic review

Meta-analysis systematic review
A type of statistical approach of quantitative Include selecting evaluation & synthesizing all
synthesis of all evidence date and studies available evidence and studies
available

Forest Plot
• It is a graphical representation of estimated results from a number of studies on the same plot.
• Like we do multiple study analysis in systematic review & Meta-analysis.
• Interesting thing about forest plot is these things depict (or) address same question results along with
overall result.
• It is also known as Blobbogram.

Fig.3: Forest plot

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EBM

• In the left side different studies are depicted. You can see there are 5 different studies are represented
by the name of author and the year in which these studies were published respectively.
• In forest of these studies the result are depicted on the plot. In the forest plot the values represented
results of individual studies along with the results the horizontal lines which are there they depict 95%
confidence intervals & odds ratio.
• In the bottom all the summary measures of all the 5 studies are also depicted in the form of single value
which is known as “Diamond” (or) the summary measure.
• In this particular forest plot odds ratio value is exactly depicted on the Right side along with the values
of confidence intervals also.
• The vertical line is the “Line of Null effect”.
• In epidemiology if Odds ratio is one it implies there’s no association between cause & effect.
• If any confidence interval is touching or crossing the null effect line it implies that study results are not
significant (inconclusive)
• Look at study number 1, 2, 3 their confidence interval includes null effect line (or) hence these are
inconclusive (or) insignificant results.
• In the bottom two studies value is > 1 for odds ratio and the confidence interval does not include 1,
definitely these are conclusive are significant results.
• The value of summary measure is given as 2.2 along with it the confidence interval is also given (1.9 – 2.4)
is 95% CI.
• Now we can conclude the summary measure of these 5 studies are statistically significant.
• Narrower the CI higher the power of the study
• For studies 4 & 5 the CI is quite narrow so they have higher power

Diamond
Summary Measure

Fig.4: summary Measure

• Summary measure of the forest plot
• It has overall odd’s ratio 2.2
• Has CI of (1.9 - 2.4) [1 is not included statistically significant]
• Diamond value is precisely 2.2 (the edges the diamond is the 95% confidence intervals.)

FUnnel PlOt
1. It is a type of SCATTER PLOT
2. Depicts Treatment Effect Vs Precision
3. Used in Systemic Reviews & the Meta – analysis
4. To detect BIAS, Systematic Heterogenecity
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5. To detect “Publication Bias”.

Fig. 5: funnel plot

Fig. 6: funnel plot

evidence Based Medicine [eBM]

MA
Sys. Review
RCT
RC > PC
CC
CS > E
Opinion, views
Animal Research
In Vitro Research

Fig. 7: eBM pyramid

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EBM

• Top of EBM - Meta-Analysis

• Gold std for EBM - Meta-Analysis
• Father of EBM - DL SACKETT

Case Report study → Report of a single case of a disease

Case series study → Report of a multiple cases of a disease
Pre-post clinical trial → Rabies ~ 100% fatal disease

• If the new drug R is beneficial, then all patients are benefited

EG will act as their own RG
– EG-Experimental group
– RG-Reference group
• If it is not beneficial, no change in the outcome, as rabies is ~100% fatal

KaP studies - Used in family planning studies

Knowledge
Attitude
Practices
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Disease Causation, Measurements and Milestones

ASSOCIATION AND CAUSATION

ASSOCIATION
Concurrence of two or more variables more often than would be expected by chance

 SPURIOUS ASSOCIATION - FALSE

 INDIRECT ASSOCIATION
 DIRECT (CAUSAL) ASSOCIATION
–– •– ONE TO ONE CAUSAL
–– •– MULTIFACTORIAL CAUSATION

Theories of Disease Causation

1. Theory of spontaneous Generation → Given by Aristotle
2. Germ Theory of Disease → by Louis Pasteur
3. Multifactorial causation of disease → by PattenKoffer
4. Web of causation → by McMohan & Pugh
5. Epidemiological Triad → Agent, Host, Environment (closed → interaction b/w them)
6. Epidemiological Triangle → Agent, Host, Environment, Time at center
7. Advanced Model of Epidemiological Triangle → Agent is replaced by causative factors Not Only
Environmental Factors, but also Nutritional, Genetic psychological factor required, Host (Group or
population)

Factor 1

Reaction at
Factor 2 cellular level Disease

Factor 3

Fig.1: Multifactorial causation

Epidemiological Triad Epidemiological Triangle Adv. EPIDEM. TRIANGLE

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8. BEINGS MODEL
B Biological & Behavioral factors
E Environmental factors
I Immunological factor
N Nutritional factor
G Genetic factor
S Social, Services & Spiritual factor

Fig. 2: Web of causation

Tools of Measurement in Epidemics

a
Rate → × 1000 a is part of b (multiplier is not 100)
b

a
Ratio → a is not a part of b (Do not look at multiplier)
b

a
Proportion → x 100 = % a is part of b (Multiplier is 100)
b

New cases
→ Incidence → × 1000 →–Rate
Total population at risk
New + old cases
→ Prevalence → × 100 →–Proportion
Total pupulation
Females
→–Sex Ratio → × 1000 →–Ratio
Males
No. of deaths
→ Case fatality Rate → × 100 →–Proportion
No. of cases
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Disease Causation, Measurements and Milestones

CFR of Rabies ~100%

CFR of JE ~ 30-35%
No. of infants births
→ IMR → × 1000 →– Rate
live births
No. of M. Deaths
→ MMR → × 100000 →– Ratio
Live births

Fig. 3: John Snow

→ Father of Epidemiology → John Snow

→ Father of Modern Epidemiology → John Snow
→ Father of Medicine → Hippocrates
→ First true Epidemiologist → Hippocrates
→ First distinguished Epidemiologist → Syndenham
→ Father of Public health → Cholera
→ National Institute of Epidemiology → Chennai
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Definitions and Concepts

HEALTH [WHO, 1948]

It is state of complete physical, mental and social wellbeing of an individual, not just an absence of Disease/
Infirmity and an ability to lead a socially and economically productive life..

Dimensions of Health
P – Physical
S - Social
M - Mental
E - Emotional
S - Spiritual
S – Socio-economic
E - Environmental
N - Nutritional
C - Cultural
E – Educational

Positive Health
• Perfect functioning of body and mind which includes Biological, Psychological & Social components.

Spectrum of Health
• Health & Disease lies on a spectrum

• Health is Dynamic

Natural History of Disease

• Evolution of Disease over a period of time in the absence of any Intervention.

• Earliest (Pre-pathogenesis) → → → → → Recovery, Disability or Death (pathogenesis)

• Best studied by “COHORT STUDY”

Stages:
1. Stage of Susceptibility

2. Stage of Subclinical disease

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PSM

3. Stage of Clinical disease

4. Stage of Recovery, Disability or Death

Disease Cycle:
1. Incubation – Entry of organism to development of 1st sign and symptoms.

2. Prodrome – Vague symptoms & difficult to Diagnose.

3. Fastigium – Signs and symptoms appear and person is maximally infective to others.

4. Defervescence – Decline of sign and symptoms.

5. Convalescence – Recovery starts.

6. Defection – Pathogen is killed or Remission.

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PQLI, HDI, MDPI, BPL

PQLI, HDI

Physical Quality Of Life Index Human Development Index

1. LiteracyRate 1. LiteracyRate/Knowledge/me anyearof Schooling/Ed-

ucation index/Enrollment Ratio Mean years of schooling
[Preferred]
2. Infant Mortality 2. Income/Income per capital/US $ PPP PPP - Purchasing
Power Parity
3. Life Expectancy1Year (LE1) 3. Life Expectancy Birth/ LEo/Longevity at birth
- Range - 0<PQLI<100 • Range - O <HDI< +1
- Value for India-65 • Value for India - 0.633 [Rank-132] Medium development
Value for Switzerland - 0.962 [Rank 1] Most develop-
ment country

HDI Calculation (Goal Posts) Minimum Maximum

MYS 0 13.1

EYS [Expected Yrs of schooling] 0 18

EDUCATION INDEX 0 0.978
INCOME [PPP] 100 107,721 $
LE Birth 20 yrs* 83.4 yrs*

* MYS – Mean Years of Schooling

• HDI is complimentary to HPI Human Poverty Index

HUMAN POVERTY INDEX

• Earlier category HPI-1 [for Developing countries]; HPI 2 [for Developed countries]
• Now - MDPI [ Multi Dimensional Poverty Index ]
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MDPI [ Multi Dimensional Poverty Index ]

Range 0 < MDPI < + 1

INDIA 0.121 [27.5% poor]

Interpretation of MDPI (DEPRIVATION %)

20-33.33% • Vulnerable to poverty

> 33.33% • Poverty
> 50 % • Severe Poverty
Overall • Deprivation in > 1/3 is Poverty

BPL [Below Poverty Line] CRITERIA

1. CALORIC INTAKE
• Rural → < 2400 K.cal/Day
• Urban → < 2100 K.cal/Day
2. INCOME PER CAPITA

Tendulkar committee 2011- 12 Rangarajan committee 2013-14

Rural < 27/-per day Rural < 32/- per day
Urban < 33/- per day Urban < 47/- per day
22% BPL 29.5% BPL

3. Income per capita [World Bank]

• Extreme Poverty < US $ 1.90 per Day
• Moderate Poverty < US $ 3.10 per Day
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Time Distribution, Epidemics

TIME DISTRIBUTION OF DISEASE

I. Short term Fluctuations
[Days - Weeks - months] → Epidemic
II. Long term Fluctuations
[Decades] → Secular Trend [Slow rise or slow fall]
III. Periodic Fluctuations [Repeatedly]
• Seasonal Trend → ↑ or ↓ in a particular season
• Cyclical Trend → ↑ or ↓ in a population after a gap of every few Years.

Examples

1. Food poisoning • Epidemic

2. Bhopal Gas Tragedy • Epidemic (Methyl ISO Cyanide [MIC] exposure on 3-12-1984)
3. Chernobyl Tragedy • Epidemic; Cesium [Cs], Iodine [I2] & Strontium [Sr] Exposure on 26-04-
1986

Fig. 1: Secular Trend

4. Seasonal Trend- • Malaria Dengue in Rainy Seasons

• Respiratory infection in winter seasons
• heat stroke in summer
5. Cyclical Trend • Measles - Once / 2-3 yrs
• Rubella - Once / 5-8 yrs
• Influenza show max. cyclical trend b/c of variations
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Drift [d/t point mutation]

Max. Antigenic variation
Shift [d/t genetic reassortment]

Fig. 2: Cyclical, Seasonal Trend

TYPES OF EPIDEMICS
1. Singe Exposure, Point Source Epidemics

Fig. 3: SEPSE
2. Multiple Exposure, Point source Epidemics

Fig. 4: MEPSE

• Multiple peaks are Known as SECONDARY WAVES(Secondary Peaks)

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Time Distribution, Vitamin
Epidemics
A

3. Propagated Epidemics

Fig. 5: PE

• 1 case of TB not on treatment can give rise to 10-15 cases/years [not more cases d/t Sub clinical
immunity]
• Only shown by diseases which have PERSON - PERSON TRANSMISION
• May show SECONDARY WAVES some times

BGT [Bhopal Gas Tragedy] → Single Exposure Point Source Epidemic

CT [ Chernobyl Tragedy] → Single Exposure point source Epidemic
HIV / STD → Propagated Epidemic [ Person - Person Transmission]
HIV/STD [Commercial Sex Workers] → Multiple Exposure Point Source Epidemic
Polio [If in India Now] → Propagated Epidemic

1. EPIDEMIC
• No. of cases of a disease clearly in excess of normal expectancy

2020 6000
2021 4000
2022 4200
2023 5000 cases E NO
15000 E YES

Normal Expectancy of Polio in India → 0

if 1 case reported → Epidemic

MCQ. No. of cases of Disease > Mean + 2 SD → Epidemic

Mean → 5000 cases/yr
SD → 800 cases/yr
Epidemic → 5000 + (2) (800) → > 6600 cases /year

• New Disease Occurrence is EPIDEMIC

• Reoccurrence of Disease is EPIDEMIC
• Exotic disease is always EPIDEMIC
2. ENDEMIC
• “Constant or Continuous Presence” of a disease in a population
• Endemic Diseases in India
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ƒ Measles, Mumps, Rubella, Chicken Pox, Pertussis

TB, HIV, Cancers, Diabetes, HTN, CHD
• Epidemics can arise from Endemics also

Fig. 6: Endemic

3. PANDEMIC

• Country - to- country spread

• E.g.
ƒ H1N1 [Swine Flu]
H5N1 [Bird flu]
HIV
Ebola
Zika
H7N9
COVID-19

4. SPORADIC
• Scattering of cases in Time, Person E.g.
ƒ Arsenic Poisoning - Snake Bite

DISEASE showing Epidemic, Endemic, PANDEMIC & SPORADIC → INFLUENZA

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Elimination, Eradication, Surveillance

CONTROL
• Reduction of transmission to such a low level that it stops to be Public Health problem
• ↓ Incidence, ↓ Duration, ↓ Financial Burden, ↓ complications

ELIMINATION
• Complete interruption of transmission but Organism still present
• Regional [country] term
• Eliminated from India-
1. Guineaworm [Dracanculiasis] Feb 2000
2. Leprosy Dec 2005
3. Maternal Tetanus, Neonatal July2016
Tetanus
4. Yaws July2016

Elimination level for leprosy < 1 case/ 10,000 population

Elimination level for NNT < 1.0 case/ 1000 Live Births

INDIA given FREE STATUS for

2 diseases – Polio (27-3-2014) &
Trachoma (8-12-2017) Fig. 1: Guineaworm

ERADICATION
• Complete extermination of organism
• Global term
• All or None phenomenon + nt
• Eradicated Diseases globally
1. SMALL POX [8th May 1980] - only disease eradicated until now - last case reported in 1977 in somalia
2. Polio virus Type 2 on 20th September 2015 and Type 3 on 24th October 2019
3. Rinderpest [cattle Disease]

Monitoring Analysis of performance of routine measurement

Surveillance Ongoing systematic process of all factors affecting a disease] data
collection, compilation, analysis & Interpretation and its application
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PSM

Monitoring Surveillance
• Continuous overlooking progress of activity • Continuous scrutiny of all Factors affecting a
disease with attention, authority & suspicion
• No inbuilt action component • Inbuilt action component ispresent
• No Feedback • Feedback is inbuilt
• One time linear process • Cyclical continuous process
• Smaller concept • Broader concept

TYPES OF SURVEILLANCE
1. Passive → Patient reports to health system on his own [90%]
2. Active → Health System goes to community in search of cases [8-10%]
seen in 4 NHPs of malaria by MPW [M] once/fortnight, Polio by SMO [surveillance MO],
TB by ASHA | TB supervisor, Kala Azar by House to House visit
3. Sentinel → Used to identify missed/Hidden cases seen in NHP, OF HIV [in blood bank, Ante Natal
clinic, STD clinic]

LEVELS OF PREVENTION OF DISEASE

Level Definition Modes of intervention
PRIMORDIAL • Before the emergency of Risk factors • Health Education
PRIMARY • Risk factor present But no disease • Health promotion & Specific
protection
SECONDARY • Disease possibly has started in the body • Early diagnosis & Treatment
TERTIARY • Disease in Progression/Over • Disability limitation & Rehabilitation

• Primary can prevent the Disease/outcome

• Secondary can not prevent the Disease/outcome

EXAMPLES
• Measles vaccines administered at 9 month of age
– At 9 months maternal antibodies are disappear → Risk Factor for measles vaccination → Specific
protection
– Primary level of prevention
• Tetanus Toxoid
– Injury [Risk factor] present
Primary
– specific protection for Tetanus
• Hepatitis B Vaccine for medical professionals
– Risk is present
Primary
– specific protection
• Rabies [post exposure] vaccine
– Risk factor present
Primary
– specific protection
• Rabies [Pre exposure] vaccine
– Risk factor is present
Primary
– specific protection
All vaccines including Covid vaccine and BCG vaccination by default comes under primary prevention
[Except, When BCG is used for Rx of Bladder cancer → SECONDARY prevention]
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Elimination, Eradication, Surveillance
Vitamin A

• Condoms [HIV] Primary

– Risk factor [HIV/STD] + Specific protection
• Condoms[ pregnancy (outcome)] Primary
• Combined OCPs, IUDs, Sterilization Primary
Majority of contraceptive methods by default comes under PRIMARY PREVENTION {except in
situations like - combined OCPs in PCOD → SECONDARY [Rx]}

Sputum smear Examination for AFB • SECONDARY[Diagnostic]

CXR for pneumonia • SECONDARY [Diagnostic]
Peripheral blood smear for malaria • SECONDARY [Diagnostic]
Blood culture in Typhoid • SECONDARY [Diagnostic]
Pap smear [screening Test] • SECONDARY [Early detection]
• DOTS for TB • SECONDARY [Rx]
• MDT for leprosy • SECONDARY [Rx]
• ACT For malaria • SECONDARY [Rx]

• DOC for malaria chemo prophylaxis Doxy or mefloquine - PRIMARY [specific protection]
All screenings /All Diagnostic tests by default are SECONDARY Level Prevention

Crutches in Polio • TERTIARY [ Locomotory Rehabilitation]

Physiotherapy in Polio • TERTIARY [Disability Limitation & Rehabilitation]
Spectacles • TERTIARY [Disability Limitation & Rehabilitation]
IOL for cataract • SECONDARY [Rx]
LASIK • SECONDARY [Rx]
MOSQUITO NETS • PRIMARY [specific protection]
Mosquito repellents • PRIMARY [specific protection]
DDT • PRIMARY [specific protection]
Gambusia • PRIMARY [Specific protection]
Source reduction for mosquitoes • PRIMORDIAL
Father asked his son,
• Not to adopt bad habits • PRIMORDIAL
• Leave his bad habits • PRIMARY [Health promotion]
• Son leaves bad habits on advice of • PRIMARY [Specific protection]
father
Preserving Traditional lifestyle • PRIMORDIAL
Changing lifestyle • PRIMARY [Specific protection]
Fetal USG • SECONDARY [early Dx]
IFA Pregnancy • PRIMARY [specific protection]
Folic Acid 3 Months before conception • PRIMARY [specific protection]
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Mobile eye clinic • SECONDARY [Early DX]

Seatbelt/helmet • PRIMARY [Specific protection]
Monitoring of BP • SECONDARY [early Dx]
Best level of Prevention • Primordial
Best level for NCD [Non comm. Disease] • Primodial
Best level for TB • Secondary
Best level for Leprosy • Secondary

OThER KEY DEFINITIONS & CONCEPTS

ICD-11 [2018]
[International Classification of Disease 11th Edition]
• Revised every 10 years
• 3 Volumes
– I - Tabular list
– II - Reference guide
– III - Alphabetical Index
• Chapter 26 and v, x

SPECTRUM OF A DISEASE
1. Disease
2. Impairment → Loss of any anatomical/physiological/psychological function
3. Disability → Unable to perform Routine activity [according to age & sex]
4. Handicap → unable to fulfil social Role

RTA [Road Traffic accident] Disease Diabetes

Loss of Hand Impairment Erectile Dysfunction
cannot DRIVE Disability No sexual Activity
Unemployment handicap Divorce
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Cases, Carriers

CASES
Primary case → First case of a Disease in a population
Secondary → All cases Who develops from Primary case
Index case → First case that ‘comes to notice of investigator ‘ [primary/sec]
Incubation Period → Time interval between Entry of organism till 1st Sign/Symptom
Median IP → Time taken for 50% cases to occur
Serial Interval → Interval/gap b/w primary & secondary case
Generation time → Time gap b/w Entry of organism till max. Infectivity
Latent Period → Time gap b/w onset till first Detection [Corresponding term to IP for non
communication diseases]

CARRIERS
Contact • carrier who develops infection from a case

Paradoxical • develops infection from another carrier

Chronic • carrier who sheds organisms > 6 months

Incubatory • sheds Organism even in IP

Convalescent • sheds organism even in Recovery

Pseudo • carrier of avirulent organisms

ICEBERG PHENOMENON

Fig. 1: ICEBERG PHENOMENON

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Tip Clinical cases Apparent cases

Diagnostic tests used
Secondary level of prevention
Hidden/submerged • carriers latent
Inapparent cases
Preclinical Subclinical
• screening is used
• secondary level of prevention
Line of Demarcation • lies between Inapparent &apparent cases

No carriers No Iceberg phenomenon

In Measles, Tetanus,
Rubella ,Pertussis, Rabies

Isolation Quarantine
Done for Cases Healthy contact
Till Recovery Till Maximum IP
Yellow fever-6 days (IP-2-6 days
Plague-40 days detention
Level of prevention Secondary Primary

INDICATORS IN HEALTH
1. Mortality indicators / Morbidity indicators

1. Mortality indicator Morbidity indicator

CDR Incidence
IMR Prevalence
MMR Admission rates
U5MR Duration of sickness
NNMR Discharge rates
Life expectancy (only positive indicator) Spells of sickness
CFR Notification rates
PMR

2. Disability indicators

Event type Person types

1. Bed disability days 1. Motility limitations
• Confined to bed days
• Confined to room
• Special aid in getting around
2. Work loss days 2. Activity limitations
• Activity of daily living
• Major activity
3. Restricted activity Days
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Cases,
Vitamin
Carriers
A

• Sullivan index [DFLE – disability-free life expectancy]

• DALY [disability adjusted life years]

Years lost due to Disability or Premature Death
Best Indicator of disease burden

• QALY [Quality adjusted life years]

Years of life lived in PERFECT H.
• HALE [Health adjusted life expectancy]
Years a newborn is expected to live in full health
• YPLL [Years of potential life lost]
Years lost due to premature death

3. Socio-economic indicators
[Mnemonic – H Flagged]
– Housing
– Family size
– Literacy rate
– Available per capita calorie
– Growth rate
– Gnp per capita
– Unemployment
– Dependency ratio

4. Standard of living
[Mnemonic - HISON HERO]
– Housing
– Income
– Sanitation
– Occupation
– Nutritional
– Health
– Education
– Recreational
– Others

STANDARDISED (ADJUSTED) RATES

[CDR- not used now]

A. DIRECT STANDARDISATION (when ASDR[age specific death rate] available)

↓
ASDR applied to STANDARD POPULATION
↓
Expected death in each age group
↓
Total deaths
× 1000
Total population
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B. Indirect standardisation (when ASDR not available)

SMR = Observed Deaths

1.
Expected Deaths
2. Regression
3. Lifetable analysis
4. MvA
5. Index DR
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VACCINES AND COLD CHAIN

Concepts and Classifications

IMMUNITY
ACTIVE
Formed within body Long Lasting
• Infections
• Vaccines
Passive
Form outside body then transferred to body, Immediate but short lasting
• Immunoglobulins
• Vertical Transmission

ClassIfICaTIoN of VaCCINes
Live Killed Toxoids Protenaceous
BCG Pertussis Diphtheria Acellular Pertussis
OPV RABIES TETANUS Anthrax
MEASLES IPV Corbevax
MUMPS Hep A
RUBELLA MENIN-
Y. FEVER GO-COCCAL
VARICELLA KFD
TYPHORAL JE Killed Polysaccharide
JE LIVE H1N1 Typhim-Vi
H1N1 LIVE Killed Pneumo-cocccal
ROTAVIRAL Covaxin Meningo-coccal
Zoster Hib
Cholera
Plague

Combination Glycoconjugate
Recombinant
MMR PNEUMOCOCCAL
HEPATITIS B
MR DPT MENINGOCOCCAL
HPV
Pentavalent HiB

PENTAVALENT – DPT, HepB, HiB

Viral Vector based - Covishield, incoVacc, Ebola
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National Immunization Schedule 2023-24

• Component of UIP [universal Immunization programme] 1985 [earlier Name – Expanded Programme of
Immunization [EPI, 1978]
• UIP is a part of RCH Programme under National health Mission [NHM]
Start at birth & completes at 16 yrs of Age for boys
[For girls additional Td during pregnancy] TT in pregnancy
At Birth → BCG, OPVo, Hep B
6 Weeks → DPT1 OPV1 HepB1 Hib1 Rota1 FIPv1 PCv1
10 Weeks → DPT2 Opv2 HepB2 HiB2 Rota2
14 Weeks → DPT3 Opv3 HepB3 HiB3 Rota3 FIPv2 PCV2
9 Months → Measles 1 or MR1, VitA [1 lakh], JE Live 1, PCV-
Booster, fiPV3
Every 6 month → Vitamin A [2lac IU each] till 5yrs
16-24 month → DPTB OPVB, Measles 2 or MR-2, JE Live -2
5 Years → DPTB
10yrs → Td
16 years → Td
[TT in pregnancy has also been
replaced by Td]
PENTAVALENT VACCINE → DPT, HepB, HiB by IM
TOTAL VITAMIN-A Dose in → 17 LAC IU
NIS

No. of Doses Under NIS

OPV → 5-6
TT → 7
BCG → 1
Diphtheria → 5+2
Pertussis → 5
Hep B → 3
HiB → 3
Rota Viral → 3
JE live → 2
PCV → 3
Measles → 2
MR → 2
FIPV [ID] → 3
FIPV (IM) → 4
Vitamin A → 9
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DelayeD ImmUNIzatIoN [Under NIS]

BCG → Till 1 year age Pentavalent → Till 1yr age
OPV → Till 5 yrs age FIPV → Till 1yr age
DPT → Till 7 yrs age PCV → Till 1yr age
Hep B → Till 1 years age
HiB → Till 6 years age
Rota Viral → Till 12 month age
Measles/MR → Till 5 years age
JE → Till 15 years age
Vitamin A → Till 5 years age
Td → Till 16 years age

CoNtRaINDICatIoNS, aeFI
Contraindications
1. Pregnancy → All live vaccines C/I Except YF vaccine
– Attenuation → Reduction of Virulence & Maintenance of
Antigenicity
– Pregnancy is a immuno-compromised State

2. HIV Postive → All live vaccines C/I

Asymptomatic Adult → No vaccine C/I
Symptomatic Adult → All live vaccines C/I except MMR, Varicella, Zoster
Newborn → All live vaccines C/I except OPV, Measles
3. Immunosuppression → All live vaccines C/I
Corticosteroids
4. Lactation → Y. fever vaccine C/I
5. Fever → Typhoid vaccine, Covid-19 Vaccines C/I
Diarrhea → No C/I
PEM → No C/I
Epilepsy → DPT vaccine C/I (Pertussis) (Active progressive Disorder)
Cerebral palsy → No C/I
6. During Epidemic → All vaccines C/I except Measles
• Vaccines require 6-8 Wks to form immunity
• Max. IP of common disease causing epidemics is <21 Days
• C/I in Intra epidemic
• Indicated In Interepidemically

measles
Q. Measles IP Period
ƒ IP - 10-14 Days
10th Day Fever starts
1. 10 days
14th Day rashes start 2. 12 days
ƒ IP of Vaccine induced measles → 7 days 3. 14 days
ƒ Post exposed vaccine must be used Within 3 days of exposure 4. 16 days
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National Immunization Schedule
Vitamin
2023-24
A

1. Post Disaster All vaccines C/I except

Measles Vaccine
2. C/I together Yellow fever & Cholera
(Maintain a gap of 3 wks)

aeFI [adverse events following Immunization]

• Observation period after administration of vaccine 30 minute
• Most common vaccine associated with

1. Paralysis • OPV
2. Hypersensitivity • Hep B > DPT
3. Shock • Hep B > DPT
4. TSS • Measles

OTHER AEFIs
1. GBS → Killed Influenza vaccine
2. Intussusception → Rota Viral
3. Fever → Pertussis [DPT]
4. Febrile Seizures → Measles
5. HHE [Hypotensive Hyporesponsive Episode] → Pertussis
6. Persistent Inconsolable crying → Pertussis
7. Osteomyelitis → BCG
8. LAP [Lymphadenopathy] → BCG
9. Brachial neuritis → TT
10. Thrombocytopenia → MMR
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Cold Chain in India

COLD CHAIN
• Maintenance of temperature of all vaccines from Point of Manufacture to Point of Administration.
• Temperature of cold chain • +2°c to + 8°c (ALL VACCINES)
OPV [long-term storage] • - 15°c to - 25°c
Yellow fever vaccine • -30°c to + 5°c

Fig. 1: WIC/WIF

State/Regional Walk in cold Rooms (WiC) +2°c to +8°c 3 Months

Walk in Freezer (WiF) -15°c to - 25°c
CHC/District Large ILR +2°c to +8°c 1 month
Large Deep Freezer -15°c to -25°c
PHC Small ILR 2°c to 8°c 1 month
Small Deep Freezer -15°c + -25°c
Sub center Vaccine Carrier +2°c to+8°c
Village Ice Pack +2°c to+8°c

• Lowest level of vaccine storage in India PHC

• Max. cold chain failure occurs at Sub center & below

ILR

Fig. 2: ILR
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• >8 hrs. of electricity/Day required [without electricity can maintain<5 Days]

VACCINe CARRIeR
• 4 Ice packs; 16-20 vials, up to 24-48 hrs

ICe pACk
• Up to 2-4 hrs, plain tap water

Fig. 3: CC Components

Open Vial policy 2015

• Applicable for Vaccines: OPV, DPT, TT, Td, Hepatitis B, Liquid Pentavalent containing HiB, IPV, PCV
• Not applicable for Vaccines: Measles, MR, MMR, BCG, JE, Rotavirus, Covid-19
• Opened vaccine vials can be used in subsequent session ‘UPTO 4 WEEKS’
• Expiry date should not pass, VVM within usability limits, Cold chain maintenance

Fig. 4: OVp
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Lyophilized Vaccines
Important, New & Covid Vaccines

LYOPHILISED VACCINE [Freeze Dried VaccinE]

• Available in Powder Form
1. BCG → Normal Saline
2. YF → Cold saline

3. MMR Distilled water Used within 4hrs except

4. Measle Sterile water YF vaccine → <1/2 Hr
5. JE → Phosphate Buffer Saline
6. Rotasil → Citrate bicarbonate buffer
7. Hib → DPT/Saline Otherwise Toxic shock
syndrome can occur
↑

• Reconstitution by Diluent

Vaccines Strains
BCG • Danish 1331 derived from M. bovis
Time required is 13 yrs [239 serial subcultures] for single dose
OPV • P1, P2, P3 [Bivalent P1, P3 used now]
Measles • Edmonston Zagreb (MC) Moraten Schwarez
Mumps • Jeryll Lynn
Rubella • RA 27/3
Yellow fever • 17D
Varicella • OKA Strain
JE Killed • Nakayama,Beijing P3
JE live • SA-14-14-2 (used now)
H1N1 • A7/California/ 2009
Rabies • Fixed viral strain
Typhoral • Ty 21 a
Mosquirix • RTS, S (AS 01)
Anti HIV • MVA [modified vaccinia ANKARA]
IPV • Trivalent P1 P2 P3
COVAXIN • NiV-2020-770
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Role of Compounds
AL (OH)3 in DPT → Adjuvant [ antigenicity]
Thiomersal in DPT → Preservative
MgCl2 in OPV → Thermostabilizing agent
Efficacy of Single dose
• BCG → 0-80% [≈50%]
• Measles → > 90%

NOTE: 2 doses is Known as “AMMRS” (Accelerated Measles Mortality Reduction Strategy)

• Rubella → >95% [highest]

First vaccine → Edward Jenner [small pox vaccine]

Term ‘vaccine → Louis Pasteur
Term ‘vaccination’ → Edward Jenner

SWITCH
t OPV b OPV India → 25th April 2016
P1 P2 P3 P1 P3
Fig. 1: E. JENNER

MISSION INDRADHANUSH
→ 7 Vaccine Preventable disease
1. Polio
2. Diphtheria
3. Pertussis
4. Tetanus
5. TB
6. Measles
7. Hepatitis B
8. Rota Virus
9. MR
10. IPV
11. JE Fig. 2: SWITCH
12. HiB
13. PCV
100% coverage by ‘catchup campaigns’ irrespective of previous immunization status by 2020

VACCINE VIAL MONITOR (VVM)

Fig. 2: VVM
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Lyophilized Vaccines Important, New & CovidVitamin
Vaccines
A

• Marker of cold chain maintenance of vaccine ≈ Potency of the vaccine

Covid Vaccination India

First Dose 16 January, 2021
100 Crore Doses 21 October, 2021
200 Crore Doses 17 July, 2022

IMPORTANT VACCINES IN INDIA

Fig. 4: BCG
1. BCG Vaccine
LIVE, Attenuated, Lyophilised vaccine
Reconstituent – NORMAL SALINE
Strain– DANISH–1331 (VIA M. BOVIS, 239 SC FOR 13 YR)
Dose – 0.05 (upto 28 days, then 0.1 ml) ID,
just above insertion of left deltoid
Efficacy – 0-80% (MEDIAN-50%)
Dose- at birth, 1 TU in 0.1 ml
20 years protection {no protection against pulmonary TB}
Fig. 5: Measles Vaccine
2. Measles Vaccine
LIVE, Attenuated, Lyophilised, Freeze dried
Reconstituent - STERILE WATER
Strain - EDMONSTON ZAGREB
Doses- 0.5 ml SC RT. ARM @ 9 month,
16-24 month (6 MONTHS GAP ATLEAST)
1 dose – 90% efficacy – life long protection
Note: Use Within 4 hours of reconstitution
Most common vaccine a/w TSS
VIM (vaccine induced measles) – IP= 7 days Fig. 6: M, MR, MMR
MUMPS - JERYLL LYNN STRAIN
RUBELLA – RA 27/3 STRAIN

3. DPT (Triple Vaccine)

2 TYPES:
a. TOXOID (D,T) b. KILLED/ ACELLULAR (P)
Doses- 0.5 ml, IM on anterolateral aspct of thigh
NIS- 6w, 10w, 14w - Primary Immunisation
16-24 m and 5 years – Booster
[Dropout in b/w – don’t restart the schedule, continue from where the child left]
Adjuvant – Al(OH)3 [Per dose - D(25Lf), P(20 million), T(5Lf)] Fig. 7: DPT
THIOMERSAL as Preservative
Adverse events-due to PERTUSIS component - Persistant Inconsolable Crying, neurological complications,
FLOOPY INFANT or hypotensive hyporesponsive episode
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4. TT
Replace with Td vaccine at 10 years, 16 years and in pregnancy
THIOMERSAL as preservative

5. Hepatitis B Vaccine
Types: Plasma derived & Recombinant (HBsAg based- use in NIS)
0.5 ml, IM at 6, 10, 14 weeks OR
0, 6, 14 weeks if institutional deliveries

Fig. 8: Td, RVV

6. ROTA virus vaccines

4 Types – but 2 used in nis
ROTAVAC and ROTASIL (live, att., lyophilized with diluent citrate bicarbonate buffer)

1 dose = 0.5 ml ROTAVAC

1 dose – 2.5 ml with 6 ml syring ROTASIIL

In both - 3 doses – 6, 10, 14 weeks
(Complication - INTUSUSSEPTION)

7. JE Vaccine
LIVE ATT., lyophilized freeze dried
Strain – SA-14-14-2 strain… diluent – phosphate buffer saline (PBS) Fig. 9: JE
Dose – 0.5 ml subcutaneous in left upper arm
@ 9 m & 16-24 m under NIS [upto 15 years]

8. HiB (H. influenzae b) –

Component of Pentavalent (DPT + HepB + HiB)
Dose- 0.5 ml IM @ 6, 10, 14 weeks
upto 6 months—3 doses
7-12 months—2 doses
1-6 years – 1 dose only

Fig. 10: Vitamin A

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Lyophilized Vaccines Important, New & CovidVitamin
Vaccines
A

9. PCV (Pneumococcal Conjugate Vaccine)

PCV-13 – (4 dose vial)– 3 doses- 6, 14 weeks and 9 months age
13 serotypes- 1, 3, 4, 5, 6a, 6b, 7f, 9v, 14, 18c, 19a, 19f, 23f

10. VITAMIN A
Preventive measure
Strength – 1 lac IU/ml
Dose- 9m – 1 lac IU followed by 2 lac IU every 6 months up to 5 years
Total 17 lac IU- specific plastic white spoon(Field instrument)

11. OPV SABIN –

LIVE Attenuated Bivalent- P1 & P3
Each dose – 2 drops = 0.1 ml @ birth, 6w, 10w, 14w,
followed by booster doses @ 16-24 month and at 5 years
Thermostabiliser – MgCl2
Adverse events- paralysis – 2 types
1. VAPP (P3)
2. VDPV (P2)
IPV SALK- INACTIVATED, KILLED – ID on upper arm
Trivalent (P1, P2 &P3)
3 doses- 6w, 14w and 9 months

12. Yellow Fever Vaccine

LIVE Attenuated vaccine, lyophilized
Reconstituent- cold physiological saline
Cold chain temp. requirement - -30° to +5°c
Validity of vaccination certificate- 10 days till life long
use with in half an hour of reconstitution
Strain – 17 D strain
Dose- 0.5ml SC on deltoid

13. HPV Vaccines Fig. 11: YF

Cervarix–bivalent–HPV 16, 18
Gardasil-quadrivalent–HPV 16, 18, 6, 11
Recommended–onset of puberty in both girls and boys
Gardasil 9 – NONAVALENT – HPV 16, 18, 6, 11, 31, 33, 45, 52, 58

WHO SAGE Criteria

• 9-14 yr.- 1-2 doses
• 15-20 yr. – 1-2 doses
• >20 yr. -2 doses
• Immunocompromised state- 3 doses
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NEW VACCINES

1. Malaria

Fig. 1: MOSQUIRIX
MOSQUIRIX (CSPpf + EP HBsAg)
• Recombinant protein based vaccine\
• 1st licensed malaria vaccine
• Efficacy – 26-50%

2. Dengue

Fig. 2: DENGVAXIA

DENGVAXIA (PrM +EP of 17DYF)

• WHO endorsed 1st dengue vaccine
• Live recombinant tetravalent vaccine (D1, D2, D3 & D4)
• Reconstituent – NORMAL SALINE
• Strain – CYD-TDV
• Doses – 3 @ 0,6,12 months (for 9-45 years of age)

3. Leprosy
MIP vaccine
• Mycobacterium indicus pranii
• By GP TALWAR @ NII, DELHI
Given with 1 dose of RIFAMPICIN
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Lyophilized Vaccines Important, New & CovidVitamin
Vaccines
A

4. Covid Vaccines:
4A. Covishield (AZD 1222/ ChAdOX1)
• NON-replicating adenoviral vector based vaccine
• For age> 18 yr. – 2 doses of 0.5 ml eash IM in deltoid (GAP- 12-16 w)
• Can be used in pregnancy and lactation
• Cold chain temp.(for all covid vaccines) - +2 to +8°C
• Efficacy – 70-80%

4B. Covaxin (BB152- By Bharat Biotech)

• 100% indigenous vaccine
• 100% whole virion inactivated
• For Age ≥ 15yr. – 2 doses 0.5 ml each IM on deltoid (GAP – 4-6 w)
• Strain – NiV – 2020-770
• Efficacy – 80%

4C. CORBEVAX

Fig. 3: CORBEVAX
• By Biological E Ltd
• RB Domain proteinaceous subunit vaccine
• Indigenous 100%
• For age 12-14 yr. – 2 doses of 0.5 ml each IM deltoid (GAP – 4w)
• HETEROLOGOUS BOOSTER dose (for COVISHIELD and COVAXIN)

4D. iNCOVACC
• INDIA’S 1ST INTRANASAL vaccine
• non-replicating adenoviral vector v.
for age ≥ 18 yr. - 2 doses of 8 drops each i.e. 0.5 ml (4 drops in each nostril) [GAP of 4w]

Fig. 4: iNCOVACC
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Vaccination For Elderly (CDC)

1. Influenza If ≥ 60 yr.
2. Pneumococcal • HERPES ZOSTER
3. Td – every 10 years • HepA, HepB
• Menningococcal v.
Immunoglobulins • MMR
1. HEPATITIS (in ml/kg BW) • Varicella v.
• YF v.
A. 0.02
B. 0.05-0.07
C. 0.05
2. MEASLES – 0.25ml/Kg BW
3. RUBELLA – 20 Ml
4. HRIG – 20 IU/Kg BW
5. ERIG – 40 IU/Kg BW
6. TIG- 250 units for prophylaxis 3000-6000 units for t/t.

ANTI RABIES VACCINE

A. POST-EXPOSURE—
• IM- ESSEN Regimen – 1-1-1-1-1 (DAY 0, 3, 7, 14, 28)
• ID- THAI UPDATED RED CROSS Regimen
2-2-2-0-2 (2 DOSES each on DAY 0, 3, 7, 28)
B. PRE-EXPOSURE—On DAY 0, 7 & 21/28
C. POST-EXP. In vaccinated—on DAY 0 & 3.

ROLE of AL(OH)3 in DPT – ADJUVANT

THIOMERSAL in DPT – PRESERVATIVE
MgCl2 in OPV -- STABILISER
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SCREENING OF DISEASE
Definition and Concepts

Screening
Search for an unrecognized Disease or Defect in apparent Healthy by means of RAPIDILY APPLIED TESTS

Screening Diagonosis
Applied On • Populations • Individuals
BASED ON • One criteria • signs / symptoms, c/f
COST • cheaper • expensive
TIME • Faster • Time consuming
ACCURACY • Inaccurate • Accurate
BASIS OF Rx • X ••

Why to do Screening (LEAD TIME is the advantage gained)

SurvIvAL AnALySIS
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• Colonic cancer has highest 5 year survival post screening.

Nhp Examples

Screening Diagnosis
TB • cough > 2 wks • sputum smear ex. (AFB-ZN Stain)
• CBNAAT
MALARIA • Fever • PBS for MP( JSB stain)
LEPROSY • Hypo anesthesia • Clinical Examination
HIV • ERS [ELISA RAPID SIMPLE] • western Blot assay
Breast CA • Mammography, MRI, BSE, Palpation, • FNAC, Biopsy
USG, Thermography,
CERVICAL CA • Visual Inspection with 5% Acetic • colposcopic Punch Biopsy
Acid [VIA] > PAP Smear
PROSTATE CA • Prostatic specific antigen + DRE, • Biopsy
PSA, DRE
Oral cancer • Bi Manual Oral Palpation • Biopsy
DIABETES • RBS • FBS> 126 mg/Dl OGTT>200 mg/Dl
HbA1c> 6.5%
Lung Cancer • Chest X-RAY • Biopsy, HRCT

Types of Screening
MASS SCREENING → Applied on large population; Eg: CXR in elderly
HIGH RISK/SELECTIVER S. → Applied in high risk group; Eg: HIV in commercial sex workers
MULTIPHASIC SCREENING → > 2 tests to large no. of people, Eg. annual Health check ups
MULTIPURPOSE SCREENING → > 1 test applied for > 1 disease, E.g. HIV, HBV, HCV in Preg.
OPPORTUNISTIC SCREENING → Screening of RHD in school children

Types of Screening

Prescriptive S Prospective S.
DOnE FOr ONE’S OWN BENEFIT OTHER’S BENEFIT
EXAMPLES PAP SMEAR IMMIGRANT S.
RBS CSW HIV
ELISA HIV BLOOD V UNIT HIV
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Properties of ST

PROPERTIES OF SCREENING TEST

HW DISEASE
Ө –
ELISA + a b
Screeing test TP FP
Results – c d
FN TN

a TP
SENSITIVITY → × 100 × 100
a+c TP+FN
SPECIFICITY → d × 100
TN × 100
b+d TN+FP
PPV [Positive Predictive Value]
a × 100 TP × 100
a+b TP+FP
D
NPV [Negative Predictive] × 100 TN × 100
C+D TN+FN
1. out of those diseased , few report positive on ST -Sensitivity
2. out of those positive on ST, Few actually are diseased → PPV
3. Those diseased as well as positive also → True Positive

PREVALENCE Total no of cases × 100

a+c × 100
Total Population a+b+c+d
a+d
ACCURACY × 100
a+b+c+d
Q. Sensitivity → 80 × 100 = 80% HIV
100
+ –
Specificity → 60 × 100 = 60%
100 ELISA + 80 40
80
PPV → × 100 = 66.6%
120 – 20 60
NPV → 60 × 100 = 75%
80
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Baye’s Theorem, ROC, Precision and Accuracy

METHOD 1
(Use 100 Instead of 1 in Denominator)
Q. Sensitivity-90%, specificity -90%, Prevalence-10%, PPV=?

Sensitivity x prevalance
→ PPV × 100
[sens x prev] + [(1–spec)(1–prev)

90x 10
→ PPV x 100 → 50%
(90x 10) + (10x 90)
(METHOD 2
Step 1 → Make a 2x2 table
Step 2 → Total Population = 1000 [hypothetic all]
Step 3 → Prevalence→10% →Total cases = 1000 x 10% = 100
Step 4 → Total cases - 100; No disease - 1000-100 = 900
Step 5 → Sensitivity - 90%; a = 90 & C = 10
Step 6 → Specificity - 90% , d = 810, b = 90

Step 7 → PPV= a x 100 = 50%

a+b
• PPV depends on sensitivity, specificity , Prevalence
• Pretest Probability of Disease » Prevalence and Post test probability » PPV

Screening Tests in Series and Parallel

One test both tests
[+ve result] → together
After other
COMBINED SERIES PARALLEL
SENSITIVITY Decreases Increases
SPECIFICITY Increases Decreases
PPV Increases Decreases
NPV Decreases Increases
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ROC CURVE [ RECIEVER OPERATOR CHARACTERISTIC CURVE]

• Sensitivity α 1/specificity
• TRADING OFF b/w sensitivity & specificity

Fig. 1: ROC CURVE

LIKELIHOOD RATIOS
Concept of LIKELIHOOD RATIOS.
• It ST is Positive – DOES NOT GUARANTEE THE PRESENCE OF DISEASE
• It ST is Negative – DOES NOT GUARANTEE THE ABSENCE OF DISEASE.
* ST – Screening Test
How much is the increase in chances of having a disease if ST is positive
Likelihood Ratio (of a ST)
How much is the decrease in chances of having a disease if ST is negative?
• Provides DIRECT Estimate of chance of having a disease, based on RESULTS of a test (change in ODDS)

LIKELIHOOD RATIO FOR A POSITIVE RESULT (LR+)

Probability test is (+)ve in diseased person True Positives
LR + = Sensitivity = =
1–Specificity Probability test is (+)ve in non–diseased person False Positive
Sensitivity of PAP smear – 80%
Specificity of PAP smear – 80%
1. What is LR+
LR + = 0.80 = 0.80 = 4
1–0.80 0.20
Interpretation
Actual chance of cervical Ca -↑ed by 4 times If PAP Smear is positive.
2. How much ODDs of Having the disease “Decreases” if ST is (-) ve ??
1+Sensitivity = Probability test is (–)ve in diseased person False Positives
LR+ = =
Specificity Probability test is (–)ve in non–diseased person True Positive

Likelihood Ratio of A Negative Result (LR-)

1—Sensitivity
LR– = = 1–0.80 = 0.20 = 1/4
Specificity 0.80 0.80
Interpretation – Actual Chance of having a disease has decreased by 1/4th
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Baye’s Theorem, ROC, Precision andVitamin
Accuracy
A

Likelhood Ratio & Odds.

Interpretation – Actual Chance of having a disease has decreased to 1/4th
• LIKELHOOD RATIO & ODDS

Post–test ODDS = Pre–test Odds × Likelihood Ratio

PRECISION VS ACCURACY
Repeatability close to true/actual value is Accuracy (VALIDITY)
Consistency, Reproducibility, Repeatability is PRECISION (RELIABILITY)

Fig. 3: PRECISION AND ACCURACY

• Student BP → 120/80

140/96 Precise
BPAPP-1 140/96 Inaccurate
140/96

140/96 Inaccurate
BPAPP-2 100/80 Imprecise
60/40

120/80 Precise
BPAPP-3 120/80 Accurate
120/80

122/82 Accurate
BPAPP-4 120/80 Imprecise
118/78
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TESTS

Precision/Reliability Accuracy/Validity
• R-Chart • 01. Levy Jennings Chart [LJC]
• Range chast • 02. Mean Chart
03. Shewart Control Chart

Validity/Accuracy
to what extent a test measures what is purports to measure!
• SENSITIVITY
• SPECIFICITY

Types of Validity

Internal V. Extent to Which Study Est. Trust Worthy Relationship B/W Cause &
Effect
External V. Generalised to Other Populations
Criterion V. Beast Measure of V.
Comparison with Gold Standard
Expressed as Sens and Spec
Conclusive V. Defines if there is A Relationship
Face/Logical V. Relavance of a Measure Appears Obvious
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COMUNICABLE DISEASES
General Epidemiology

COMMUNICABLE DISEASES GENERAL EPIDEMIOLOGY

Period of Communicability

FROM Prior to TO

C. Pox → 2D RASH 5D

Measles → 4D RASH 5D

Rubella → 7d before symptoms 7 days post rash

Mumps → 4-6 before symptoms 7 days post rash

Influeza → 1-2D symptoms 1-2D

Diphtheria → 14-28 D from onset

Pertussis → 7D post exposure ↔ 3 wks post paroxysmal stage

Meningococcus → Until absent from the nasal / throat discharge

Polio → 7-10 D Symptoms 7-10 D

Hepatitis A → 2 Wks Jaundice 1 Wk

Hepatitis B → Till disappearance of Hbs Ag & appearance of Anti HBS Ag

TB → As long as not treated

HIV → Life long

Tetanus → None

Specimens For Diagnosis

TB → Sputum [smear]

Malaria → Blood [smear]

Leprosy → None

HIV → Blood
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H1N1
Influenza Nasopharyngeal secretions

Diphtheria Covid-19 Nasopharyngeal secretions

Chickenpox → Vesicle fluid [microscopy]

Rabies Living person → Biopsy of skin follicles on nape of neck > corneal scrapings

Rabies Dead person → Brain Biopsy

Rabies Living Dog → Brain Biopsy

Rabies Dead Dog → Brain Biopsy

VERTICAL TRANSMISSION MC Time

Varicella → 2st Trimester

Rubella → 1st Trimester

Syphilis → 3rd Trimester

Toxoplasmosis → 3rd Trimester

CMV → 3rd Trimester

Hep B → 3rd Trimester

Hep C → During Delivery

Herpes V → During Delivery

HIV → During Delivery

Parvo Virus → 2nd Trimester

INCUBATION PERIODS

Measles 10-14 Days [10 Days]

Rubella 14-21 Days

Chicken Pox 14-16 Days

INFLUENZA 18-72 hrs [1-3D]

H1N1 1-4 D

Diphtheria 2-6 D

M. Meningitis 3-4 D

TB Weeks-yrs
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General Epidemiology

HEPATITIS
A → 15-45 D [2-6 wks]
B → 45-180 D [6 wks - 6 months]
C →30-120 D
D → 30-90 D
E → 21-45 D [3-6 WKS]

Polio → 4-33 D [~ 7-14 D]

Cholera → 1-2D

Typhoid → 10-14 D

Staph. food poisoning → 1-6 hrs

Dengue → 3-10 D

Malaria PV → 8-17 D 14 D Median IP

PF → 9-14 D 12 D MIP

PM → 18-40 D 28 D MIP

PO → 16-18 D 17 D MIP

Filariasis → 8-16 months

Rabies → 20-60 D [3-8Wks]

Yellow fever → 2-6 D

JE → 5-15 D

Plague → 1-3 D

Kala Azar → 1-4 months

Trachoma → 5-12 D

Tetanus → 6-10 D [80 → 8th Day Disease]

HIV → months -years [10 yrs]

CCF → 1-3 D

Ebola → 2-21D

Nipah → 14-16 D

Anthrax → 1-7 D

Brucellosis → 5-60 D

Zika → 3-10 D

H7N9 → 1-10 D
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NiPAH → 14-16 days

COVID-19 → 1-14 days (5.1 d)
MONKEY POX → 5-21 days
H7N9 → 1-10 days

CASE → A person with Disease, Health disorder or condition

SUB CLINICAL CASE → Inapparent, covert, missed or abortive case;
→ organism multiplies but DO NOT MANIFEST
CARRIER → Infected Person Or Animal That Harbors
Organism In Absence Of Discernible Clinical Disease

Secondary Attack Rate [SAR]

No. OF Secondary casein 1 TP
• SAR = × 100
Total Susceptible
• Proportion (%)
• SAR Measles > 90%
Mumps > .86%
C. Pox > 90%
• Measures of Communicability/ Infectivity
• Primary case is excluded from both numerator & denominator
• IP Measles 10-14 days life long immunity
– Infection
– Vaccine

Q n = 100, all <5yrs old. 33 developed Measles in 2018 and 33 others got Measles vaccine in 2019.
Now, 1 case of measles occur on 01/06/20, 11 more cases developed by 11/06/2020. SAR?
No. o Secondary casein 1 TP
= × 100 = 11 /33 × 100
Total Susceptible
= 33.3%
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Respiratory Infections

Small Pox
• Causative Agent → Variola major [Variola minor → ALASTRIM]
• Last case in India → 1975
• Last case in world → 1977 [Somalia]
• Eradication → 8th May 1980

SMALL POX:
Reasons for eradication:
• No known animal reservoir
• Subclinical did not transmit
• Lifelong immunity
• Vaccine
• No long term carriers
• Case detection - EASY

CHICKEN POX RASH S. POX

Centripetal Centrifugal
Pleomorphic Non-Pleomorphic
DEW Drops on Rose Deep seated
petals Multi locular
Superficial Affects extensor aspects
Unilocular Slow Evolution
Affects flexor
aspects, axilla
Rapid Evolution

Fig. 1: C. POX RASH

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Cause → HHV-3[α] ‘’Varicella’’

IP → 14-16 D
Source → case
Mode of Transmission → Respiratory [Air droplets]
Period of Communicability → 2D ← Rash → 5D
SAR → 90%
Vaccine → OKA strain [ Live Attenuated ]
Late complication → Shingles by Recrudescence

MEASLES
Cause → RNA Paramyxovirus
IP → 10-14 D[10 Days]
Source → Cases [No carriers-No ice berg phenomenon]
Mode of transmission → Respiratory[Air droplets]
Period of communicability → 4D ← RASH → 5D
SAR → > 80%
Pathognomy CF → Kolpik Spot [opp. to lower 2nd molar]
Cfs → Retro auricular origin of rash
Mc complication → Otitis Media [Serous]
Late Rare complication → SSPE [Sub Acute Sclerosing Pan Encephalitis]
7/million cases • after 7-10yrs
Vaccine → Live attenuated
Distilled water- Diluent
9 m & 16-24 m, 0.5ml, S/C in Rt Arm
Edmonston Zagreb strain
Immunoglobulin → 0.25ml/Kg/Body weight

MUMPS
Cause → Myxovirus Parotitis
IP → 2-3 wks
Source → Case
Mode of Transmission → Respiratory (Air Droplets)
Period of Communicability → 4-6 D ← symptoms → 7 D
SAR → > 86%
MC complication → Aseptic meningitis [Child] [MC]
→ Orchitis [Adolescence]
Vaccine → Live attenuated
→ Jeryll Lynn Strain
MC age group → 5-9 yrs

RUBEOLA → Measles
RUBULA → Mumps
RUBELLA → German Measles
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Respiratory Infections

RUBELLA
Cause → RNA Togavirus
IP → 14-21 D
Source → Cases [No carriers - No Iceberg phenomenon]
Mode of Transmission → Resp. [Air droplets]
Period of Communicability 1 Wk ← symptoms → 1 wk. after rash
Vaccine → Live attenuated RA 27/3 strain C/I in pregnancy
1st priority group → Non pregnant Non Lactating Reproductive 15-49 yrs female [1st
trimester]
Congenital Rubella Syndrome → CVD [PDA], Cataract, Sensory Neural Deafness

INFLUENZA
Cause → Orthomyxo Virus Type A [ MCC of Epidemics ]
Type B [Only cause of Pandemics]
Type A Epidemic - once / 2 - 3 years
Type B Epidemic - once / 4 - 7 years
Type C Epidemic - once / 10 - 15 years
MC Type → H3N2
SWINE FLU → H1N1
Avian Flu → H5N1
Avian Flu [China 2013] → H7N9
Avian Flu [China 2021] → H10N3
Antigenic variations Antigenic Drift Antigenic shift
D/t point mutation D/t genetic reassortment
Gradual Sudden
Sporadic EPIDEMIC / PANDEMIC
IP 18 - 72 hrs [1-3 D]

H1N1 [SWINE FLU]

2009, Mexico
Risk factors Child/ Infants <2yrs
Pregnancy
Old aged > 65 yrs
COPD
Chronic Heart Disease
Chronic Renal Disease
Chronic Hepatic Disease
On Aspirin therapy
Morbid Obesity
Lab Diagnosis RT- PCR [most sensitive]

Sample Nasopharyngeal Swabs

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DOC 1. Oseltamivir
75 mg BD x 5 Days
2. Zanamivir

BIRD FLU, H5N1 BIRD FLU, H7N9

1997, Hong Kong 2013, China

DOC - Oseltamivir DOC-Oseltamivir

Zanamivir

Vaccine 1. Live [Nasal vaccine]

2. Killed
Strain - A7/ California 2009
Priority group - Pregnancy
- > 6 m child chronic disease
- 15-49 yrs adults

REVISED / NEW GUIDELINES ON CATEGORIZATION OF SEASONAL

INFLUENZA A H1N1 CASES 2019-20
CATEGORY A CATEGORY B1 CATEGORY B2 CATEGORY C
Mild Fever Category A Category A Category A&B
Plus Plus Plus Plus

Cough/Sore throat with High-grade fever Children with mild risk Breathlessness,
or without Body Ache, Severe sore throat factors Chest pain,
Head Ache, Diarrhea, Pregnant women Pregnant women, DROWSINESS
Vomiting ≥ 65 yrs of age Patients HYPOTENSION
with Lung disease / Hemoptysis
Heart disease/ Liver somnolence,
disease/ Kidney disease
High persistent Fever,
/ Blood disorder / Dia-
betes/ Neurological inability to feed well,
disorders/ Cancer/ Convulsions,
HIV | AIDS | Long Shortness of
term cortisone therapy breath,
Difficulty in
Worsening of
chronic disease
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Respiratory Infections

TREATMENT GUIDELINES
No testing Home isolation Home isolation Immediate
hospitalization
No oseltamivir May need oseltamivir Give oseltamivir Immediate
hospitalization
t/t of symptoms No testing No testing required Start oseltamivir
Home isolation BSA where required Send throat swab
Reassess after 48 hr.
BSA : Broad Spectrum Antibiotics

DIPHTHERIA

Cause Corynebacterium Diphtheriae Carriers as Main

Source Carriers [95%] > Cases source :

IP 2 - 6 days * Diphtheria

Mode of Transmission Resp [ Air Droplets ] * M. Meningitis

Period of communicability → 14-28 days from onset
[Non communicable is ≥ 2 cultures, 24 hrs apart is negative]
Vaccine DPT ( 6, 10, 14 Wks )
16 - 24 Months
5 years
Toxoid 0.5 ml IM

Stain Albert (cuneiform/ chinese letter)

Schick Test Fig. 2: DIPHTHERIA

Immunity status Test → Intradermal Hypersensitivity Test 0.2 ml Shick toxin given Reading > 96 hrs
1. Positive-Susceptible to Diphtheria Mx - Immediate Immunization
2. Negative- Immune, Mx - Nothing
3. Pseudo +ve - Hypersensitive, Immune, Mx- Nothing
4. Combined- Hypersensitive, Susceptible Mx Desensitization
→ Replaced by Hemagglutination inhibition Test
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Treatment of Diphtheria
TREATMENT Antitoxin units – ERYTHROMYCIN [D.O.C.]
Anterior nasal d. 10,000 – 20,000
Tonsillar d. 15,000 – 25,000
Pharyngeal/laryngeal d. 20,000 – 40,000
Nasopharyngeal d. 40,000 – 60,000
Extensive d. 80,000 – 120,000

Pertussis / Whooping Cough/100 Day Cough

CAUSE BORDETELLA Pertussis
IP 7-14 DAYS
Source CASES [ No CARRIERS, No SUBCLINICALS]
SAR >90%
DOC Erythromycin
VACCINE DPT WEAKEST component

Meningococcal Meiningitis/Cerebrospinal Fever

Cause → N. Meningitidis [A[mc], B,C,D,29E,W135,x,y]
IP → 3-4 D
Source → Carriers >Cases
Routes of Transmission → Resp, Air Droplets
CFR → >80%, without Rx & with Rx → <10%
DOC
Cases → Penicillin
Carriers → Rifampicin

Chemoprophylaxis Rifampicin
Vaccine → Killed Cellular Fraction

Not for ‘B’ → C/I in Pregnancy & Age < 2yrs

Not immunogenic → First priority group - Early Adolescence
[10-13 yr]
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Respiratory Infections

ARI Pneumonia
New ARI Guidelines, IMNCI [Integrated Mx Of Neonate & Child, India] 2017-18 [RCH]

Signs Classify as Identify Treatment

(Urgent pre-referral treatment are in bold print)
• Any general danger SEVERE • Give first dose of an appropriate antibiotic.
sign or PNUMONIA OR • Refer Urgently to ospital
• Chest indrawing or VERY SEVERE
• Stridor in calm child DISEASE

• Fast breathing PNEUMONIA • Give an oral Amox for 5 days.

• 2-12m RR > 50 • Soo the the throat and relieve the cought with
• 12m-5y RR > 40 as safe remedy.
• Advise mother when to return immediately
• Follow-up in 2 days
• No sign of penumonia NO PNEUMONIA: • If coughing more than 30 days, refer for
or very severe disease COUCH OR COLD assessment.
• Soothe the throat and relieve the cough with a
safe remedy.
• Advise mother when to return immediately.
• Follow-up in 5 days if not iproving.

CHECK FOR GENERAL DANGER SING

Asl Look:
• Is the child able to drink or breastfeed? • See if the child is lathargic or unconscious.
• Does the child vomit everything?
• Has the child had convulsions?
A child with anygeneral danger sign needs URGENT attention: complet ethe assessment and any
pre-referral treatement immediately so referral is not delayed.

THEN ASK ABOUT MAIN SYMPTOMS:

Does the child have cough or difficult breathing?
OF YES, ASK: LOOK, LISTEN: Classify Cought
• For how long? • Count the breaths in one minute. or Difficult
• Look for chest indrawing CHILD MUST Breathing
• Look and listenfor stridor. BE CLASSIFIED

If the child is: Fast breathing is:

2 months up 50 breaths per
to 12 months minute or more

12 months up 40 breaths per

to 5 years minute or more

# if referral is not possible, see the section here referral is Not Possible in the module Treat the child.
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TUBERCULOSIS/WHITE PLAGE →
Period of communicability → As long as not treated
Barometer of Social Welfare in India
Cause → M. tuberculosis
Mode of T → Resp, Air Droplets
Source → Cases [Human, Bovine]
IP → Weeks - months - Year.

Fig. 3: MTB

EPIDEMIOLOGY OF TB-INDIA
Country with highest TB Burden India
ARI 1.5 %
Infected with TB 40%
Developing TB/day 5000/day
SS +ve per year 0.8 million
Deaths per year 0.37 million
1 Case of TB infects/year 10-15 persons/year
Incidence of Infections [ARI] 1-2% [Tuberculin Conversion Index]
Prevalence of infection 40% [Tuberculin Test]
Incidence/Prevalence of disease Sputum Smear Examination
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Respiratory Infections

Immunity Status Test Montoux Test

Antigen → Purified Protein Derivative
Tuberculin → 50,000 TU / mg
Strain → PPD RT-23 with tween 80
Dose → 1 TU in 0.1 ml
ID on flexor aspect of forearm
Reading → 72 hrs [ Induration - Horizontal Max ]
> 9 mm → Positive - Infection [current, past]
6-9 mm → Doubtful
< 6 mm → Negative - Never Infected
False +ve → BCG High Coverage Faulty Technique
False -ve → HIV,Immunosuppression, Pertusis, Measles, Chicken Pox
→ Type IV Delayed Hypersensitivity
Vaccine → BCG
Live attenuated
Danish 1331 From M. Bovis by 239 Serial sub cultures over 13 yrs
Normal Saline - Diluent
At birth,
0.05 ml < 28 days age
ID above Deltoid
0.1 ml ≥ 28 days age
0-80%
(0% against pulmonary TB - 50% against severe forms)
Duration of protection → 20 years [not Lifelong]
National TB Institute [NTI], Bangalore / TB Research center [TRC], Chennai
National Institute for TB & Respiratory Diseases [NITRD], Delhi
• MC opportunistic infection of HIV in India
• TB DM is an independent risk factor for TB
• MDR TB = Resistance to Isoniazid & Rifampicin XDR TB
• XDR TB = Resistance to
1. INH & RIFAMPICIN both ⊕
2. Any one Fluoroquinolones ⊕
3. Any one second injectable
• Bedaquiline OR • Linezolid

TB is a propagated epidemic
• Anti TB Day 24 March
• Robert Koch TB Bacillus

END TB STRATEGY
Strategy Vision → TB Free world
1. Reduction of TB incidence rate → >90%
2. Reduction of Deaths → >95% By 2035
3. Tb affected families facing
Catastrophic costs → Zero.
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Covid-19, Mucormycosis

COVID – 19 DISEASE
Introduction
Corona Virus disease 2019 – COVID-19
Cause SARS-COV 2 [Severe Acute Respiratory Syndrome Corona Virus-2]

SARS-COV 2 – positive sense ssRNA

SUBFAMILY Orthocoronaviridae
FAMILY Coronaviridae
GENUS Betacoronavirus
ORDER Niridovirales
REALM Ribavirae

Fig. 1: CORONAVIRUS-2
IP – 1-14 days (5-6 days)
Source – Case
Mode of transmission – Air droplet, Fomites
Period of C. – 1-3 days Prior to Symptoms till
1-2 weeks – asymptomatic
3 weeks – mild, moderate disease
> 3 weeks – severe
VOC – Variants Of Concern
OMICRON (B.1.1.529)
VBM – Variants Being Monitored
ALPHA B.1.1.7; BETA B.1.351; GAMMA P1; DELTA B.1.617.2; N/A ZETA
EPSIOLON ETA IOTA KAPPA
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COVID SITUATION (Till March 31, 2023)

WORLD (in millions) INDIA (in millions)
CASES 681 44.7
DEATHS 6.81 0.53
RECOVERIES 654 44.1
CFR 1.0 % 1.18 %

TIMELINE FOR COVID-19

India
30 JAN., 2020 – 1ST CASE THRISSUR, KERALA
25TH MARCH 2020 – 1ST LOCKDOWN
16TH JAN., 2021 – 1ST VACCINE DOSE

Overall
December,2019 PUE: WUHAN CITY. HUBEI, CHINA
07 Jan., 2020 Ncov (novel corona virus)
13 Jan., 2020 THAILAND
30 Jan., 2020 PHEIC
11 Feb., 2020 COVID-19, SARS-COV 2
11 Mar., 2020 GLOBAL PANDEMIC
08 Dec., 2020 1ST VACCINE, UK

RISK FACTORS
• Age > 60 years
• Comorbidities: CVD, CBVD, DM, HTN, Immunosuppression, Chronic disease

CLINICAL FEATURES:
Fever, cough, myalgia, headache, sore throat, coryza
ANOSMIA – loss of smell
AGEUSIA – loss of taste

CLINICAL PRESENTATION:
3-TIER H. facility
SEVERITY Health facility
(INDIA)
MILD Symptomatic, case Home, CCC (covid care centre) Isolation beds
definition
MODERATE Pneumonia DCHC (dedicated covid h. cen- Isolation beds + oxygen
tre)
SEVERE Severe pneumonia DCH (dedicated covid hospital) ICU beds
CRITICAL ARDS DCH ICU beds
CRITICAL Sepsis DCH ICU beds
Septic shock
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Covid-19, Mucormycosis

DIAGNOSIS OF COVID-19
A. MOLECULAR TESTING
Samples – LRTI – BAL, tracheal aspirate, sputum
URTI – Throat swab (oropharyngeal) OR
Nasal +throat swab OR
Nasopharyngeal swab

TESTS:
CT SCORE
A. Molecular Tests • 35 – Negative report
• NAAT- RT PCR [Gold Standard] • 25-35 – Moderate viral load
• Can calculate CT SCORE (Cycle Threshold) + transmissibility
• ANTIGEN • < 25 – Severe viral load +
• ANTIBODY transmissibility

B. Chest Imaging
• CXR – Pneumonia
• CT SCAN – HRCT
• USG

C. Lab Test
• NLR (increase), D-Dimer(increase), LDH(increase),
• CRP(increase), TLC(decrease), Procalcitonin(normal)

Aarogya Setu APP

02 April, 2020 – Mobile application
• Surveillance of cases
• Nearby cases
• Risk of getting covid

TREATMENT PROTOCOL ADULTS

1. Mild Disease - URTI (HOME isolation & case )
• Physical distancing, masks & sanitizers
• Symptomatic care with monitoring of temp. & oxygen

2. Moderate Disease (WARDS)

• Define as RR ≥ 24, breathlessness OR SpO2 90-93%
• Oxygen support with SpO2 92-96%
• Inj. Methylprednisolone (Anti-inflammatory)
• LMWH/Unfractionated heparin (Anti-coagulant)
• Monitor CRP, D-Dimer, B. sugar, CBC, LFT, KFT

3. Severe Disease (HDU,ICU)

• Define as RR ≥ 30/min, breathlessness & SpO2 < 90% on RA
• HIV, HFNC, Intubation, Ventilator
• Inj. Methylprednisolone (Anti-inflammatory)
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PSM

• Euvolemia
• Sepsis, shock Mx
• Monitor via CRP, D-Dimer, B. sugar, CBC, LFT, KFT

DISCHARGE PROTOCOL
Severity Rtpcr Required/Not Protocol
MILD No • 10 days post development of symptoms
• No fever for ≥ 3 days
MODERATE No • Fever resolve for ≥ 3 days & no O2 support required
• NOTE- don’t discharge if symptom present or dependance
on O2 therapy
SEVERE Yes • Clinical improvement

COVID-19 VACCINES
BASIS Examples
RNA Moderna
Pfizer biotech
VIRAL VECTOR Oxford Astrazeneca
Covishield
Cansino, Jansen
Gameleya, Sputhnik
iNCOVACC
WHOLE VIRION BASED Sinovac
Sinopharm X2
Medicago INC
Covaxin
PROTEIN SUBNIT NovaVAX
ChineseAOX
CORBEVAX

COVID VACCINES
4A. Covishield
(AZD 1222/ ChAdOX1)
• NON-replicating adenoviral vector based vaccine
• For age> 18 yr. – 2 doses of 0.5 ml eash IM in deltoid (GAP- 12-16 w)
• Can be used in pregnancy and lactation Fig. 2: Corbevax
• Cold chain temp.(for all covid vaccines) - +2 to +8°C
• Efficacy – 70-80%

4B. Covaxin
(BB152- by Bharat Biotech)
• 100% indigenous vaccine
• 100% whole virion inactivated
Fig. 3: Covishield
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Covid-19, Mucormycosis

• For Age ≥ 15yr. – 2 doses 0.5 ml each IM on deltoid (GAP – 4-6 w)

• Strain – NiV – 2020-770
• Efficacy – 80%

4C. Corbevax
• By Biological e ltd
• RB Domain proteinaceous subunit vaccine
• Indigenous
• For age 12-14 yr. – 2 doses of 0.5 ml each IM deltoid (GAP – 4w)
• HETEROLOGOUS BOOSTER dose Fig. 4: iNCOVACC

4D. iNCOVACC
• INDIA’S 1ST INTRANASAL vaccine
• non-replicating adenoviral vector v.
• for age ≥ 18 yr. - 2 doses of 8 drops each i.e. 0.5 ml (4 drops in each nostril) [GAP of 4w]

MUCORMYCOSIS:
[Black fungus]

Predisposing Factors
Hyperglycemia (DM)
DKA
Organ transplantation
Trauma
Fig. 5: Mucormycosis
Neutropenia
Burns, Hematologic Disorders
Co-morbidities
Breakthrough infection
T/t with Deforaxime, steroids, BSA
Prolonged ICU stay

MICROSCOPY
• Ribbon like hyphae (Branch at 90°)
• ANTLERS ON A MOOSE appearance
• Non-septate hyphae
• Angioinvasion
• Neutrophilic invasion Fig. 6: Mucosal thickening, bony erosions
• Perineural invasion
• Hgic infarction, Coag. Necrosis

DIAGNOSIS
Biopsy and fungal culture
CT Scan – mucosal thickening & bony erosions
MRI Scan – BLACK TURBINATE sign
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PSM

Treatment
Aggressive therapy
Disfiguring – Surgical Debridement + Anti-fungal therapy

Drugs –
LAMB (D.O.C.)
Posaconazole
Isavuconazole

PREVENTION
1. Avoid contact with decaying organic matter
2. Among covid patients
• Prophylaxis AF’s
• DM/DKA Mx
• Avoid steroids/BSA
• Clean DW in O2 therapy
• Early reporting of symptoms

Fig. 7 Black Turbinate sign

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Intestinal Infections

INTESTINAL INFECTIONS
Poliomyelitis
World → 2 Endemic countries → Pakistan, Afghanistan
India → Polio - free on 27-03-2014
Polio Virus → Last case → 13-01-2011
P1 → MCC of Epidemics
P2 → Most antigenic
Most easily eradicable MCC of VDPV [Vaccine Derived Polio virus]
P2 Eradication → 20 Sep 2015
P3 → MCC of VAPP [Vaccine Associated Paralytic Polio]
→ P3 Eradication
→ 17 Oct 2019 [Certificate],
→ 24 Oct 2019 [Declaration]

Fig. 1: Polio
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PSM

Reservoir → Man
Route of → Faecal - Oral
Transmission IP Clinical → 4-33D [~7-14D]
Types → In apparent95%
Minor/Abortive 4-8%
Non-paralytic 1%
Paralytic<1%
Vaccine → OPV SABIN
→ IPV Salk

INTESTINAL INFECTIONS
Poliomyelitis
Diagnosis:

• Stool Culture & Virus Isolation

– Mainstay for Dx
– AFP Surveillance
• CSF Examination
• Throat Examination
• Blood Examination

HEPATITIS
A Entero V72 [PicoRNA V] → 15-45 D - Feco-oral
MC in children in India
B Hepadna virus → 45-180 D Blood
C Hepaci virus → 30-120 D sexual
D Viroid’s like → 30-90 D Parenteral
E Calicivirus → 21-45 D - Feco-Oral
MC in Adults
MCC Mortality in Pregnancy

Hepatitis B Serum Markers

HBS Ag Ist Antigen to appear[AustraliaAg],
→ Epidemiological Marker
HBC Ag → Rarely appear
Hbe Ag → Marker of Infectivity,
→ Indicates Active Viral Replication
Anti HBC → 1st Antibody to appear, Marker of Acute Hep → B [IgM]
Anti Hbe → Marker of Good Prognosis, Viral Replication has stopped
Anti HBS → Marker of end of Period of Communicability
→ Vaccinated individual
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Intestinal Infections

HEPATITIS B
Prevention
Plasma derived (HBsAg, carriers) - SUBUNIT
Vaccine
cDNA yeast derived - RECOMBINANT
Immunoglobulin – immediate protection (given within 6 hr.) 0.05 – 0.07 mL/Kg – 2 doses with 30 days
gap

5C’s Hepatitis Testing WHO

• Consent
• Confidentiality
• Correct test results
• Councelling
• Connection

CHOLERA
Cause → Vibrio Cholerae - ELTOR [Hybrid]
MC Subtype in India now
Route of Transmission → Feco - Oral
IP → 1-2D
Cfs → Rice Watery Diarrhea

Treatment
Adults → Doxycycline
Child → Azithromycin
Pregnancy → Azithromycin
Chemoprophylaxis → Tetracycline
Epidemic → 1st step Verification of Diagnosis
Most important Prophylactic measure is H. Education

TYPHOID
Cause Salmonella Typhi
Route of Transmission Feco - Oral
IP 10 - 14 Days
Cfs PEA SOUP Diarrhea
Coated Tongue
Rose spots
Stepladder Pyrexia

Diagnosis
B Blood Culture [1st Wk] - Best Test
A Antibodies / Widal [2nd Wk]
S Stool Culture [3rd Wk]
U Urine Culture [4th Wk]
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PSM

Treatment
DOC
cases → Cephalosporins, Quinolones
carriers → Ampicillin/Amoxycillin + Probenecid x 6 wks
Vaccine → Typhoral
Typhim - Vi
TAB

ORS
Medical super discovery of last century

WHO REDUCED OSMOLARITY ORS

NaCl……. 2.6 g Na + ……75 mmol/L
KCl……… 1.5 g K+………20
Na Citrate.... 2.9 g Cl- ………65
Glucose…… 13.5 g Citrate…...10
Glucose….75

20.5 g 245 mmol/L

ReSOMAL
• Rehydration solution for Malnourished
• Sodium → Halved → 45 mmol/L
• Potassium → Doubled → 40 mmol/L

Super OrS
Rice/ Starch/Alanine Based [Not Mono Sugars]

WORM INFESTATIONS

Guinea Worm
Cause → Dracunculus Medinensis
Last case in India → July 1996 [Jodhpur] from step wells
Eliminated in India → Feb 2000
Type → Water Based, Cycle developmental
Treatment → Niridazole
Mebendazole
Metronidazole

Round Worm
Cause → Ascaris lumbricoides
IP → 2 months
Mode of T → Feco - oral
DOC → Albendazole
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Intestinal Infections

MC worm infestation in India & world

HOOK WORM (LARVA MIGRANS)

Fig. 2: Larva migranes

Cause → Ancylosoma duodenale, Necator Americanus

Mode of T → Penetrations of Skin of Foot
IP → 5 wks - 9 months [A. duodenale],
7 wks [N. Americanus]
Association → 1. IDA → 0.03 -0.2 ml/worm/Day[~0.1ml/w/D] blood loss
2. Hypo Albuminemia
Endemic Index → CHANDLER’S INDEX [CT] =No. of eggs/gm stool Eggs mea-
sured by KATOKATZ Technique
CI > 300 → Major Public health Problem

TAPE WORM
Cause → Taenia sodium T. Saginata

HOST → Definitive- Man

Intermediate - Pigs [T. Solium]
Cattle [T. Saginata]
Route of T → Consumption of contaminated meat

IP → 8-14 Wks

DOC → Praziquantel
Niclosamine
[Albendazole - for Cysticercosis]

NATIONAL DEWORMING DAY

Dates “10 February” & 10 August
Objective School & Pre-School Children
Beneficiaries 1-19 Yrs old
Linkage Vitamin A prophylaxis
Dosage Albendazole 400 mg stat
→ 1/2 tablet [1-2 Years age]
→ 1 tablet [2-19 Years age]
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VBDs, ARBOVIRAL INFECTIONS

Vector Borne Diseases

1. DENGUE
Classification →
ARBO VIRUSES
Group A Group B Others
Sind Bis JE Sandfly fever
CHIKUNGUNYA KFD CHANDIPURA
fever Dengue GANJAM
West Nile Fever Dhori
MINNAL

D1 mc subtype causing dengue

D2
Cause → Group B Arbovirus
D3
D4

Vector → Aedes Aegypti

Reservoir → Man, Aedes
IP → 3-10 Days
Diagnosis Clinically → Torniquet Test → ≥ 10 spots Dengue Fever
≥ 20 spots→Dengue haemorrhagic fever
Serological → NS-1 Antigen Test [comes +ve even in 1st week]
Presentation →

Dengue Fever Dengue Haem. Fever Dengue Shock Syndrome

Breakbone Fever Fever DHF +
Haemorrhagic features Shock
Thrombocytopenia
Haemoconcentration
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PSM

Global Strategy For Preventation & Control [2012-2020] [2021-2030]

• Reduce Dengue mortality by 50% by 2020
• Reduce Dengue morbidity by 25% by 2020 0% Fatality
• To estimate true Burden by 2015

VACCINE
• DENG VAXIA
• Live Recombinant tetravalent vaccine
Strain → CYD – TDV
Recommended Age group → 9-45 yrs
Schedule → O, 6m, 12m
Production → Replacement of premembrane and envelope
Structural genes of YF 17-D strain with
Dengue four Serotypes

2 MALARIA

IP
Cause P. Vivax → 8-17 D ~ 14 Days
P. Falciparum → 9-14 D ~ 12 Days
P. Malaria → 18-40 D ~ 28 Days
P. Ovale → 16-18 D ~ 17 Days

• MC subtype in India - Falciparum

Only cause of Death – Falciparum
• No relapse → Falciparum & Malariae [Recrudescence present]
• Infective form → Sporozoite

SPOROGONY SCHIZOGONY
Sexual cycle Asexual cycle
Exogenous phase Endogenous phase
Mosquito Man

Fig. 1: Plasmodium Lifecycle

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VBDS, ARBOVIRAL & INFECTIONS

VECTOR BORNE DISEASES: MALARIA

A. Malariometric Measures
1. Pre-eradication Era
Spleen rate – 2-10 yr. Endemicity
Infant parasite rate (IPR) – 0-1 yr. Recent transmission
2. Eradication Era
Annual parasitic incidence (API) – New Cases / TP x 1000 BEST INDICATOR
Annual blood examination rate (ABER) – Index of OPERATIONAL EFFICIENCY
Slide positivity rate (SPR)

B. Vector Indices
Human blood index – ANTHROPHILISM
Sporozoite rate
Mosquito density
Man biting rate
Innoculation rate

Diagnosis
Peripheral blood smear
a. TH ICK – Presence of Malaria --- SENSITIVITY
b. THIN – Species Identify --- SPECIFICITY

FILARIASIS
Lymphatic Brugian Form
Cause Wuchereria Bancroft Brugia Malayi
Vector Culex Quinan Fasciatus Mansonia
DOC DEC [Di Ethyl carbamazine] →
6mg/kg x 12 days
Ideal time for blood collection → 8.30 PM to 12 AM midnight

Global Program To Eliminate Lymphatic Filariasis [GPELF] [WHO]

1. Stop The Spread Of Infection→ Mass Drug Administration [MDA]
– Diethyl carbinamine Citrate [DEC] + Albendazole or
– Ivermectin + Albendazole
2. Alleviate Suffering → Morbidity Management & Disability Prevention [MMDP]
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Accelerated Plan For Elimination Of Lymphatic Filariasis [APELF], India 2018

• Triple Drug therapy of IDA [Ivermectin, DEC, Albendazole]
• Community engagement for successful MDA implementation
• DEC Medicated salt
• House - to - House visit Advocacy.

ZOONOSES
Classification of Direction of Transmission
1. Anthropozoonoses – from ANIMAL to MAN
Rabies, Plague, Anthrax, Hyadatid
2. Zooanthroponosis – from MAN to ANIMAL
Human TB in cattle
3. Amphixenosis – Either Direction
T. cruzi., S. japonicum

Classification Based on Life Cycle

1. Direct z: Directly from animal to man. Eg. Rabies, Brucellosis, Trichinosis
2. Cyclo z: 1 Vertebrate species. Eg. Taeniasis, Echinococcus
3. Meta z: Invertebrate vector. Eg. Plague, Arboviral infection
4. Sapro z: Non-animal Reservoir. Eg. Mycosis, Larva Migrans.

RABIES
Cause → Lyssavirus 1 [Rhabdo Virus family] BULLET Shaped
IP → 20-60 Days
Pathogonomic → Hydrophobia

Path of MF → Negri bodies in hippocampus

Mode of T. → Animal Bites except human & rat bite
Barrier → Water (ISlands dont have Rabies)
Local wound → Soap & Running water for 5-10 min
Rx → No sutures generally
Vaccines → Developed from fixed virus type

Fig. 2: Rabies Virus

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VBDS, ARBOVIRAL & INFECTIONS

PCECV → Purified Chick Embryo Cell Vaccine

→ RABIPUR, VAXORAB
PVRV → Purified Vero cell Vaccine
→ VERORAB, ABHAY RAB, INDIRA
HRIG → Human Rabies Immune Globulin – serum 20IU/Kg
ERIG → Equine Rabies Immunoglobulin - 40IU/Kg.
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Zoonoses

ZOONOSIS
BRUCELLOSIS – Undulant Fever / Malta F. / Mediterranean F.
– CAUSE – Brucella melitensis
– IP – 1-3 weeks
– Mode of T. – Contact (Infected tissue/blood/urine/placenta/abortvie fetus), Food, Air
– RESERVOIR – Cattle, sheep, dogs, pigs,buffalo
– TREATMENT - Tetracycline
LEPTOSPIROSIS – Pretibial Fever
– CAUSE – L. interrogans
– IP – 10 days
– Mode of T. – Infected rat urine, soil, water, air
– RESERVOIR – Wild/domestic Animals
– DIAGNOSIS – MAT (Gold s.), ELISA, PCR
– TREATMENT – Penicillin
– Px - Doxycycline
ANTHRAX – Malignant Pustule/Wool Solter’s Disease
– CAUSE – Bacillus Anthracis
– DIAGNOSIS – MB Smear
– MODE of T. – Spores
– Types – Cutaneous/Intestinal/Pulmonary
– BIOTERRORISM – Cat. A (M/c used)
– TREATMENT – Ceftiaxone, Doxycycline.

YELLOW FEVER/AMERICAN PLAGUE

Cause Flavivirus Fibric us
Reservoir Monkeys, Man, Aedes
IP 2-6 Days - Quarantine Period
CFR 80% Live Attenuated
Vaccine Strain - 17D
Diluent - Cold Physiological Saline
Temp - (-30) °C ↔ (+5)°C
Validity of Certificate - 10 Days to Life long
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PSM

Indices of Surveillance C+
1. Container Index = x 100
C
H+
2. House Index = x 100 [Aedes aegypti Index] <%
H
C+
3. Breteau Index = x 100
H

YF control measures → 1. Area around airport kept free of Aedes >400m

2. Breteau index <5%

EYE [Elimination Yellow Fever Epidemic] STRATEGY [WHO, UNICEF, GAVI]

• Preventions at - risk population
• Prevent international spread of YF
• Contains outbreaks rapidly.

JAPANESE ENCEPHALITIS
Cause Group B Arbovirus
Vector Culex Triteniorhynchus [MC in India]
Amplifier Host Pigs
Actual Host Ardied Birds [Ducks,Fowls, Herons]
Accidental Host Man
Mosquito Attractants Cattle/Horses
IP 5-15 D
CFR 30%
Age Group 1-15 yr
Vaccines Live strain SA - 14 - 14 - 2 - at 9m, 16-24 months\ [Killed strain -
Nakayama, Beijing P3 [earlier]

KFD / Kyasanur Forest Disease / Monkey Disease

Cause KFD virus
Reservoir Rats, Squirrels
Amplifier Host Monkeys
Accidental host Man
Vectors Hemophysalis Spinigera Tick [In India] Soft Tick [Outside India]
IP 3 - 8 Days
Vaccine Killed Vaccine

PLAGUE
Cause → Yersinia Pestis
Reservoir → Wild rodent [Tatera India]
Vector → Rat Flea [Xenopsylla Choopsis] -most efficient in India]
Source → Rats → (Bubonic & Septicemia)
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Zoonosi

Man → (Pneumonic)
Mode of T → Rat Flea Bite or Air Droplets
IP → Bubonic → 2-7 days→ (most common)
Pneumonic → 1-3 days
Septicemic → 2-7 days

DOC

Cases → Streptomycin
Chemoprophylaxis → Tetracycline

RICKETTSIAL DISEASES
CAUSE VECTOR RESERVOIR
Epidemic Typhus R. Prowazekii Louse Man
Typhus Group Endemic Typhus R. Typhi Flea Rodents
Scrub Typhus R. Tsutsugamushi Trombiculid Mite Rodents

IndianTick Typhus R. Conor; Tick Rodents

Spotted Fever RMSF R. Rickettsi Tick Rodents
Group R.Fox R. Akari Mite Rodents

Q Fever Coxiella NONE Cattle

others Trench Fever Bartonella Louse Man

• DOC → Tetracycline
• Brill Zinsser Disease → Recrudescence of Epidemic Typhus

LEISHMANIASIS
CUTANEOUS/ ORIENTAL Sore /
VISCERAL/KALA AZAR MUCOCUTANEOUS
Delhi boil /BAGHDAD boil
L.DONOVANI L.TROPICA L.BRAZILENCES
SAND fly [PHLEBOTAMOUS] SAND fly SAND fly [DDT IOC]

IP → 10 D 2 Years [ ~1 - 4 months]
Serological Diagnosis → κ 39 Ag & ELISA, DAT, IFAT
Immunity status test → Montenegro Test Leishmania Antigen used
Reading after 48-72 hrs
DOC → LAMB [Liposomal Amphotericin B]
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Surface Infections, STIs

Trachoma/Rough Eye [India FREE ON 08-12-2017]

IP → 5-12 days
Mode of T. → Fomites, Flies, Sexual
Field Diagnosis → Follicles on Upper Tarsal Conjunctiva, Limbal Follicles [Herbert pits],
Pannus , Conjunctival Scarring
[≥ 2 out of 4] →

WHO Classification
TIF [Trachoma Inflammation Follicular] → 5 large Follicles on Upper Tarsal Conjunctiva
TII [Trachoma Inflammation Intensity] → 50% of Deep Tarsal Vessels of UTC covered
DOC → Azithromycin
Mass Treatment if prevention of moderate/severe trachoma in <10yrs age is > 10%

TETANUS
Cause → Clostridium Tetani
Source → Soil
Reservoir → Soil
IP → 6-10 days (NNT-8Th day disease)
Period of communicability → None
NNT Elimination criteria (14 July 2016) → 1. Rate <1.0 cases / 1000 LB
2. Coverage TT >90%
3. Attended deliveries > 75%

CATEGORY CLEAN WOUND <6H Other WOUNDS

A CC/B <5 yrs None None
B CC 5-10 yrs 1 DOSE 1 DOSE
C CC > 10 yrs 1 DOSE 1 DOSE + TIG
D incomplete course/ unknown Complete course Complete course + TIG
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PSM

Leprosy/Hansen's Disease
Cause → Mycobacterium Leprae
Mode of T. → Air Droplets, Skin contact,
transplacental, Breast Feeding, Insect bite, Tattoo, Corneal,
/Organ transplantation
Epidemiology India
ANCDR [Annual New case → 9.27/1,00,000 detection Rate]
Prevalence → 0.67/10,000
Elimination level (Dec 2015) → <1 case / 10,000 pop

RIDLEY JOPLING CLASSIFICATION

TT → Highest CMI Paucibacillary
++++ Lepromin test
BT → MC in India Paucibacillary
BB Multi Bacillary
BL Multi Bacillary
LL → Highest Bacillary load Multibacillary

Most Infectious
Immune histological classification
→ First sensation lost Cold Temperature
Treatment → MDT [Multidrug Therapy]
→ Leprosy can't be Eliminated
1. No proper vaccine
2. No artificial culture media
3. Long & variable incubation period -most imp. Reason
4. Multiple Routes of Transmission

WHO GLOBAL LEPROSY STRATEGY 2021-2030

Vision – ZERO LEPROSY
Goal – ELIMINATION

Targets
1. ZERO new cases in 120 countries
2. 70% decrease in new cases
3. 90% decrease in new cases with grade-2 disability
4. 90% decrease in new cases in children

HIV/AIDS
Cause → HIV [HTLV-III, Lymphadenopathy associated virus]
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Surface Infections, STIs

Mode of T → Sexual
→ MC mode [>90%] Least efficient route [<0.01 -0.1%]
Blood → Least common mode [<0.5%]
Prevatemce → 0.22%
MC age group → 30-44 yrs

Fig. 2: HIV VIRUS

1st case → 1981 - USA

HIV Virus → 1983 - HIV1 discovery Robert Gallo - Montagnier -Sinuoussi Got NOBEL PRIZE
1986 - HIV2 discovery
1st case India Chennai 1986
Highest cases Maharashtra
High Prevalence Tamilnadu, Maharashtra, Andhra, Karnataka, Manipur,Nagaland, Mizoram
Moderate Prevalence Gujarat, GOA, Pondicherry
Highest Prevalence Mizoram [2%]
Fastest Increasing PREV Andhra Pradesh
Highest Prevalence city Mumbai
MC route in Manipur Inj. Drug users

States HRG ANC Districts

[High Risk Group] [Antenatal clinic]
High Prevalence >5% >1% A
Moderate Prevalence >5% <1% B
Low Prevalence <5% <1% C
Poor Data or Low prevalence in Last 3 yr - D
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Mother to child transmission Rate 30%

MTCT through Breast Feeding 12-16%
In Developing Countries Breast Feeding is not CI except in Higher Socio Economic females

MC Opportunistic infection in world Pneumocystis Carinii Pneumonia [Pneumocystis Jiroveci

Pneumonia]
MC Opportunistic infection in India TB [up to 40% Co-infection]

UNAIDS 90-90-90 TARGET

• Reaching 90-90-90 in 2020 means ending the AIDS epidemic is possible by 2030
• An ambitious but achievable target for HIV treatment by 2020
• 90% of People living with HIV know their status
• 90% of people those who test positive have access to treatment
• 90% of people under treatment have an undetectable viral load

UNAIDS 95-95-95 TARGET

• Reaching 95-95-95 in 2024 means ending the AIDS epidemic is possible by 2030
• 95% of People living with HIV know their status
• 95% of people those who test positive have access to treatment
• 95% of people under treatment have an undetectable viral load.

OTHER STIS
Surface Infections
5 CLASSICAL STDs
IP CAUSE
Spyhilis 9-90 Days Treponema Pallidum
LGV 3-12 Days Chlamdia TRachomatis
Ponovanosis 3-21 Days Calymato Bacterium Granulomatis
Chancroid 3-5 Days Hemophilus Ducreyi
Gonorrhea 1-15 Days Neisseria Gonorrhea

OTHER STDs,
HIV/AIDS STREPTO. GP. B
HEPATITIS B C D CANDIDA
TRICHOMONIASIS CAMPYLOBACTER
GENITAL/ANAL wARTS MOLLUSCUM CONTAGIOSUM
SCABIES UREAPLASMA UREALYTICUM
PUBLICLOUSE E. HISTOLYTICA
HHV a 1, 2, SHIGELLA
EBOLA VIRUS DISEASE MYCOPLASIMA HOMINIS
MONKEY POx HHV b
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Surface Infections, STIs

STDs/STIs INTERVENTIONS
1. Case Detection
– Screening
– Contact tracing - BEST
– Cluster testing
2. CASE HOLDING AND TREATMENT
3. EPIDEMIOLOGICAL T/t
4. PERSONAL Px
– Barrier methods – CONDOMS
– Vaccines – HBV, HPV

Suraksha Clinic
• BLOOD sample testing
• Counseling
• Syndromic case management [RTT/STI/RPR Kits]

STD COLOUR CODED KITS

COLOUR SYNDROME CONTENTS

1. Grey Urethral /Anorectal/Cervical Discharge /Scrotal Swelling Azithromycin, Cefixime
2. Green Vaginal discharge Secnidazole, Fluconazole
3. white Genito -Ulcerative disease [non-herpetic] Azithromycin poniciium
4. Blue Genito-Ulcerative disease [herpetic] (Allergic to Azithromycin, Doxycycline
Penicillin)
5. Red GUD (Herpetic) Acyclovir
6. Yellow Lower Abdominal pain Cefixime, Metronidazole
Doxycycline
7. Black Inguinal bubo Azithromycin, Doxycycline

TREPONEMATOSES

SYPHILIS YAwS PINTA

Cause T. Pallidum T. Pertenue T. Carateum

Route Sexual/Venereal Direct skin contact Direct skin contact
DOC Benzathine Penicillin G Benzathine Penicillin G Benzathine Penicillin G

Yaws eliminated from India in July 2016

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Emerging and Remerging Infections

CCHF NIPAH MERS EBOLA ZIKA

Crimean Congo Middle East Zaire EBV
Hemorrhagic Respiratory - M/C Most
Fever Syndrome Dangerous
Cause Nairo V. (Bunya Nipah V. Betacorona V. Ebola V. Zika V.
V.) (Henapi V.) (Lineage C)
Route of Hyalomma (hard Fruits eaten by Respiratory Body fluids Aedes Aegypti
Transmission Tick) Bats Camel milk/
meat
IP 1-3 days 6-21 days 2-14 ays 2-21 days 3-14 days
1st appear in Gujarat, T.N. West Bengal Saudi Arabia Congo, 1976 Gujarat, T.N.
CFR 30% 40-75% 30-35% 40%
Treatment RIBAVIRIN None (Ribavirin None Symptomatic None
(D.O.C.) in some cases)
Prevention ___ rVSV-ZEBOV Diagnosis
vaccine RTPCR
(REcombinat
Viral voctor
based)
Other points Congenital-
Microcephaly

Licthi Virus Disease

Consumption of Litchi on empty stomach by Children

Methyl Cyclo Propyl Glycine leads to Severe hypoglycemia and Death

1st case – West Bengal & Bihar
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Fig. 1: NIPAH Virus Life Cycle Fig. 2: CCHF Life Cycle

WNF Noro Virus Avian Influenza Monkey Pox

West Nile Winter Bir Flu HPAI
Fever Vomiting Bug
Cause WNF virus Noro V. H10N3 H7N9 H5N1 (Type A) Monkey Pox.
(Flavi virus) (Norwalk V) – V (Ortho pox
Calciviridae V.)
Route of Culex pipiens Faecal-oral Human Poultry Contaminated Scabs/
Transmission Sufaces to human Puultry Mean Blisters,
Poultry Sexual,
REspiratory
IP 4-21 days
1st appear in Kerala, 2021 China, 2021 China, 2013 Hongkong, 1997
CFR 3-6%
Treatment None None Oseltamivir Symptomatic Oseltamivir-75 Tecovirimat
Zanamivir mg BD x 5 days Brincidafovir
zanamivir Symptomatic
T/
Prevention Source Hand hygiee None None Cooking > 70°C Smalll pox
Reduction vaccine
Other points Bird-
Mosquito-Bird

Fig. 3: MERS Life Cycle

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Emerging and Remerging Infections

Fig. 4: ZIKA Virus Life Cycle

Fig. 5: Z WNF Life Cycle

Fig. 6: MERS Virus Fig. 7: Influenza Virus

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PSM

Fig. 8: Noro Virus Fig. 9: Ebola Virus

Fig. 10: Bird Flu

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NON-COMMUNICABLE DISEASES
CHD, Hypertension, DM

NON-COMMUNICABLE DISEASES
1. CHD
Prudent Diet
cholesterol
→ Overall Goal is to reduce Ratio→ <3.5
HDL
Dietary goals
1. Reduction of Fat intake →<30%
2. Reduction of Saturated Fat intake → <7%
3. Reduction of Salt intake → <5g/Day
4. Reduction of Cholesterol intake → <200 mg/Days
5. ↑ Complex Carbohydrates consumption
6. Avoid alcohol

Non Modifiable Risk Factors Modifiable Risk Factors

1. Age [Peak Age 51-60 yrs India] 1. Smoking
2. Sex [M>F India] 2. High BP
3. Family History 3. High S.Cholesterol
4. Genetic Factors 4. DM
5. Personality type A 5. Obesity
6. Sedentary Life Style
7. Stress
Most Direct Association→ LDL

Prevention & Control

1. LDL level →< 100 mg/dl
2. HDL level →> 40 mg/dl
3. Serum cholesterol level →< 200 mg/dl
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2. HYPERTENSION:
RULE OF HALVES TRACKING OF BP
→ Only shown by HTN

Fig. 1: HTN

HYPERTENSION:
SBP DBP JNC -VII ACC/AHA 2017
<120 and <80 NORMAL NORMAL
120-129 and <80 PRE-HTN ELEVATED BP
130-139 and 80-89 PRE-HTN STAGE-1
140-159 or 90-99 STAGE-1 STAGE-2
>160 or >100 STAGE-2 STAGE-2

Lifestyle Modification to Manage Hypertension

1. Weight reduction [Reduced by 5-20 mm Hg/10 Kg BW loss]
2. Adopt DASH [Dietary Approach to Stop HTN] diet plan [Reduce by 8-14 mm Hg]
• Diet rich in fruits/Vegetables, Low Fat dairy products
• Reduced saturated fat, Total fat
3. Dietary Sodium reduction< 100 mEq/Day [Reduce by 2-8 mam Hg]
4. Physical Activity [Reduce by 4-9 mm Hg]
• Regular Aerobic Physical Activity
• >30 min/day, most days of the week
5. Moderation of Alcohol consumption [Reduce by 2-4 mm Hg]
• Limit alcohol consumption < 2 drink/day

DIABETES MELLITUS
Diagnosis
OGTT → Venous Plasma Glucose level at 2hrs >200 mg/dl
FBS → >126 mg/dl
Hb1 AC → >6.5%
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CHD, Hypertension, DM

Glycemic Index → Area under 2 hr Glucose response curve

Low GI <55 → Fruits, Vegetables, Grains
Medium GI 56-69 → Sucrose, Basmati Rice
High > 70 → Cornflakes, White bread, Jasmine rice

4. RHEUMATIC FEVER
Cause → Group A β hemolytic streptococci [M5-MC]
Prevalence → 5-7/1000
Age group → 5-15 years of Age

Treatment
Primary → 1.2 M units single dose IM
Secondary → 1.2 M units @ 3 weekly intervals since 5 years or 18 years of age whichever is later

Revised Jones Criteria

Major Minor
Carditis Poly a [low risk] low risk population
Arthritis Mono A or poly A poly arthralgia
fever [> 38.5]
Chorea Poly arthralgia
ESR > 60, CRP > 3
[medium & high risk]
Prolonged PR interval
Erythema Marginatum
Sub Cutaneous Nodules
Moderate / High Risk P. Mono Arthralgia
Fever [> 38], Arthralgia
ESR > 30, CRP > 3.0
Prolonged PR interval

Initial ARF
2 major (or)
1 major + 2 minor

Recurrent ARF
2 major (or)
1 major + 2 minor (or)
3 minor
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Cancers, Obesity & Blindness

New GLOBOCON-WHO 2020 data

IN WORLD
Total cancer cases – 10 million
Total cancer deaths – 6 million/year

AGE STANDARDISED
Incidence rate – 201/1 lac pop/year
Death rate – 101/1 lac pop/year

WORLD INCIDENCE
S. NO. TOTAL MALES FEMALES

1 BREAST LUNG BREAST

2 LUNG PROSTATE COLORECTUM

3 COLORECTUM COLORECTUM LUNG

4 PROSTATE STOMACH CERVIX-UTERI

5 STOMACH LIVER THYROID

PREVALENCE MORTALITY

1. BREAST 1. LUNG

2. COLORECTUM 2. COLORECTUM

3. PROSTATE 3. LIVER

4. LUNG 4 STOMACH

5. THYRIOD 5. BREAST

CANCER – INDIA
Total cancer cases – 2.5 Million
Total cancer deaths – 0.3 Million / year

AGE STANDARDISED
Incidence rate – 97/1 lac pop/year
Death rate – 63/1 lac pop/year
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INDIA INCIDENCE

S. NO. TOTAL MALES FEMALES

1 BREAST LIP/ORAL CAVITY BREAST

2 LIP/ORAL CAVITY LUNG CERVIX-UTERI

3 CERVIX-UTERI STOMACH OVARY

4 LUNG COLORECTAL LIP/ORAL CAVITY

5 COLORECTAL ESOPHAGUS COLORECTAL

PREVALENCE MORTALITY

1. BREAST 1. BREAST

2. CERVIX-UTERI 2. CERVIX-UTERI
3. LIP/ORAL CAVITY 3. LIP/ORAL CAVITY

4. OVARY 4. LUNG

5. PROSTATE 5. ESOPHAGEAL

OBESITY

I. BMI / Quetlets Index

W = Kg
H2 m2

Global Classification
Underweight → <18.5
Normal BMI → 18.5 ↔ 25
Over Wt/Pre Obese → 25 ↔ 30
Obesity → ≥ 30

Percentile Classification
Underweight → < 5th
Normal weight → 5th ↔ 85th
Over Wt/Pre Obese → 85th ↔ 95th
Obesity → ≥ 95th

Indian Classification
Underweight → < 18.5
Normal Weight → 18.5 ↔ 22.99
Over Wt / Pre Obese → 23 ↔ 25
Obesity → ≥ 25
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Cancers, Obesity & Blindness

Ht cm
II. PONDERAL Index =
3 wt 3 Kg

III. BROCA’S Index = Htcm -100

Actual wt
IV. CORPULENCE Index = = Cutoff - ≤ 1.2
Desirable wt

Hcm - 150
V. LORENTZ FORMULA = (Htcm- 100) - -
2[Women], 4[Men]

VI. SFT [Skin Fold Thickness] = with Herpenden calipers

Sum ≥ 40 mm in Boys and ≥ 50 mm in Girls = obesity (sum of four sites)

1. Triceps - Single best

{ }Obesity present
≥ 18 mm in Boys
≥ 32 mm in Girls
2. Biceps
3. Suprailiac
4. Subscapular

BLINDNESS
WHO Blind → <3/60 in better eye after best possible correction
Q Visual Acuity of Rt eye <3/60 & Lt eye >3/60. Blind? → No
Q <3/60 in both eyes. Blind? → Yes
Q <3/60 in both eyes & after correction >3/60. Blind? → No

NPCBVI Blind → <3/60 in better eye after best possible correction

WHO Categories of Visual Impairment

Categories
0 >6/18
1 L Low vision → <6/18-6/60
2 E Economic Blindness → <6/60-3/60 → Work vision
3 S Social Blindness → <3/60-1/60 → Walk vision
4 M Manifest Blindness → <1/60-Perception of Light (+)
5 A Absolute Blindness → Perception of Light (−)
9 Unspecified causes
MCC Blindness → Cataract (62%) > Refractive Error (19.7%)
Low Vision → Cataract (77%)
Ocular Morbidity → Refractive error
PrevalenceUsing <6/60 → 0.36% [Latest 2019- 20 Value]

Visual impairment <6/18 – 2.55% (MCC Cataract)

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NHPS, POLICIES & LEGISLATIONS

NTEP, RNTCP

RNTCP
Revised National TB control Programme, 1992
History → NTP1962
DOTS [Directly Observed Treatment Short Course]

RNTCP 1992

Fig. 1: DOTS
Objectives → 90/90
1. > 90% Cure Rate
2. > 90% Case Detection Rate

Components of Dots →
1. Accountability
2. Good Quality Sputum Microscopy
3. Political Commitment
4. Uninterrupted Supply Of Good Quality Drugs
5. Direct Observation Therapy
New changes → CXR, CBNAAT Test in Diagnosis
2017-18 Daily Regimens & fixed dose combinations
Active case finding
Drug Resistant TB Rx
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Bed aquiline
Information Communicable Technology Enabled Adherence (DOTS99)
ICT Enabled Surveillance (NIKSHAY)
Weight Bands 4 for Adults & 6 for Children
Merger of RNTCP with NACP
No extensions for IP
Incentives ↑ ed

Diagnosis Of TB →
IGRA
1 Microscopy SEROLOGICAL
– ZN Staining
– LED Fluorescence Microscopy
2 Culture
– LJ medium
– ALC (Automated liquid culture) System BACTEC -Drug Sensitivity Testing
3 Rapid Molecular Dx Testing -Line Probe Assay
– CBNAAT [Cartridge Based Nucleic Acid Amplification Test]
Basis for Gene expert/MTB/Rif
4 Other - CXR Tuberculin Skin Test

Sputum Smears
• 2 SS over a period of 2 days after a cough of > 2 wks.
Spot → Day 1
Morning → Day 2
• ZN strain → O+/2 → SS -ive
1 + /2
SS +ive
2+/2

Fig. 1: PTB adults

Fig. 2: PTB paediatrics

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NTEP, RNTCP

Fig. 3: EPTB adults

Active Case Finding

• Door - Door Screening 15 Day campaign
• Active Surveillance by
Health Department Worker
ASHAs
TB Supervisors

FDCs [Fixed Dose Combinations]

1 Reduce pill burden
2 Lower Relapses
3 Reduction of Resistance
4 ↑ed Compliance
5 ↓ed Side Effects

Treatment Regimes - DailY [No extension of Intensive phase]

CAT 1 SS +ve
SS-ve
CAT 2 Previously Rx
CAT 4 MDR TB [DOTS+ earlier]
CAT 5 XDR TB

RNTCP DOTS Treatment

Category 1 [New SS +ve/ New SS -ve]
Category 2 [Re-treatment]
Both Categories have same treatment regimen
[New 2019-20 Guideline]
Regimen → 2[HRZE]+4[HRE] = Total 6 Month Duration

Non-DOTS Regimens
ND 1 (seriously ill) 2 (SHE) + 10 (HE) 12 m
ND 2(non seriously ill) 12 (HE) 12 m
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Pregnancy with TB
1. TB → Start ATT immediately irrespective of time of pregnancy & delivery → 2 (HRE) + 7 (HR)
2. MDR TB% Do MTP then start ATT If no MTP, then start ATT without Kanamycin &Ethionamide Substituted
with PAS till Delivery

Weight Bands
Adults(4) Pediatric (6) MDR (5)
25-39 Kg 4-7 Kg <16 Kg
40-54 Kg 8-11 Kg 16-25 Kg
55-69 Kg 12-15 Kg 26-45 Kg
≥70 Kg 16-24 Kg 46-70 Kg
25-29 Kg > 70 Kg
30-39 Kg

New Drugs → DELAMANID

→ BEDAQUILINE
ICT Based Adherence Support → DOTS - 99
– TB Blister pack has contact Number Hidden
ICT Based Surveillance Support →NIKSHAY
– All data entered & connected with Central Ministry

Incentives (Nikshay Poshan Yogana)

Patients → 500/month
Providers → Cat I _ 1000/-

Cat II _ 1000/-

Cat IV & V _ 5000/-

New Changes
• No extension of IP
• All patients – DST
• All patients – Screening of Diabetes
• NTEP merger with NACP

NTEP (NATIONAl TuBERCulOSIS ElIMINATION PROgRAM)

HISTORICAl ASPECTS & INTRODuCTION

NTP 1962
DOTS [ Directly observed Treatment Short course] RNTCP 1992
↓
1st Jan 2020
NTEP
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NTEP, RNTCP

SDG3 →Ensure healthy Lives & promote well being for all TAREGT 3.3 End Epidemic of TB

Fig. 4: NTEP

TB BuRDEN - 2.69 MIllION INCIDENCE – 27%

goal of NTEP:
Elimination of TB by 2025

Target of Ntep
• Decrease Incidence by 80%
• Decrease Mortality by 90% (Frame work used – NSP 2017-2025)

Fig. 5: END TB

NATIONAl STRATEgIC PlAN 2017-2025

Vision: “TB Free India” with zero deaths, disease & poverty due to TB
GOAL: Rapid decline in Burden of TB morbidity & Mortality Elimination by 2025

4 Pillars:
• To build, strengthen & Sustain policies
• Prevent
• Detect
• Treat
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2015 2020 2025

Incidence / 1 Lac population 217 142 44
Prevalence / 1 Lac population 320 170 65
Mortality / 1 lac population 32 15 3
Families suffering Catastrophic costs 35% 0% 0%

DIAgNOSTIC TESTS uNDER NTEP:

1. Sputum smear Microscopy
• ZN staining
• LED – FM

2. Culture
• LJ Medium
• Automated Liquid culture (ALC)
– BACTEC MGIT 960
– BACTALERT
– VERSATREK

3. Drug sensitivity testing

• Moderate Proportionate Sensitivity testing PST MGiT 960
• Economic proportionate sensitivity testing 1% LJ Medium

4. Molecular Diagnosis test:

• Line Probe Assay
LPA TB
PL LPA– INH & Rifampicin Resistance
SL LPA-FQ / SLI Resistance
• NAAT
1. CBNAAT
2. True NAT True NAT
• Developed by ICMR Real time PCR Technology
– True NAT MTB- MTB
– True NAT MTB plus- MTB
– True NAT MTB Dx- Rifampicin Resistance

Fig. 6 : CBNAAT
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NTEP, RNTCP

Fig. 7: CBNAAT

5. Chest X-Ray:
As a screening tool to ↑ sensitivity

6. TST-Tuberculin skin test

(Not used anymore)

7. Serological testing
Complete BAN → Punishable offense under Law

8. TB in HIV
LF-LAM- Lateral Flow urine Lipo AraBino Mannan

9. Skin Test for TB

C-Tb- Latent TB diagnosis. Antigen used ESTA6, CFP10

Sputum Smear
a b
Spot sample Morning Sample

Sputum Smear
Min Fields grading Result
Grading
0 AFB / 100 OIF 100 O -
1-9 100 Scanty +
10-99 100 1 +
1-10 / 1 OIF 50 2 +
>10 20 3 +

False +ve results

• If Food (or) Oil particles is present
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• If there are Scratches on the slide

• Unfiltered Carbolfuchsin
• If there is inadequate decolorization
• If there is Reading/ Reporting errors

False-ve Results
• If there is Improper / Inadequate Sputum collection
• If there is Improper storage of Sputum samples
• If there is presence of Saliva
• Smear Too thin / Too thick
• Boiling of Carbolfuchsin
• There is over decolorization
• Improper examination
• Reading / reporting errors

DEFINITIONS uNDER NTEP

Presumptive TB:
• Cough ≥ 2 weeks
• Fever ≥ 2 weeks
• Significant weight loss
• Hemoptysis
• Abnormal Chest X-ray

Presumptive TB in pediatrics:
• Cough ≥ 2 weeks
• Fever≥ 2 weeks
• Weight Loss / No weight gain in 3 successive months
• H/0 contact

Presumptive DR-TB:
• Paeds TB non responders
• TB with contact of DR-TB
• Previously treated
• New TB with HIV
• All notified new TB
• All patients found Save on follow up (treatment first line drugs including failures)
universal DST: Al new patients are offered CB NAAT test to look for Rifampicin resistance

Types of Resistance:
MR MONO R Resistance to anyone first line drug
PR Poly Resistance Resistance to more than one first line drugs (except H/R)
MDR Multi Drug Resistance Resistance to H&R in one person at the same time
XDR Extensively Drug Resistance MDR+Any one FQ+ Anyone second line injectable
RR Rifampicin Resistance Resistance to Rifampicin ± others drug excluding H
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NTEP, RNTCP

Case finding
1. Passive Voluntary Reporting to MO with Symptoms
2. Intensified: MO search for TB cases in
- DM clinics
- ART clinics
- NCD clinics
3. Active: HW seek in TB cases in key vulnerable population

6 Reference labs:
• National Tuberculosis Institute (NTI), Bangalore
• National Institute for Research of TB(NIRT), Chennai (TRC)
• National JALMA Institute, Agra
• Regional Medical Research Center (RMRC), Bhubaneswar
• Bhopal Memorial Hospital & Research center(BMHRC), Bhopal
• National institute of TB & Respiratory diseases (NITRD), Delhi

Must know facts TB / NTEP:

• Undiagnosed, SS+PTB are the source of infection
• MC symptom of PTB: Persistent Cough ≥ 2 weeks
• Main tools for diagnosis: Sputum smear, M/E, X-ray & Molecular diagnostic test
• 2 sputum smear examined (spot, early morning)
• Sputum examined < 2 days of collection, Results reported on the same day
• Important to elicit past history of anti-TB treatment
• EPTB, Contacts of all Save / PLHIV with cough should be subjected for SSM/E irrespective of duration
of cough.
• 2-3% of new adult OPD (rural PHC setting) will be presumptive TB cases, refer for sputum examination
• 10% of presumptive TB cases, are found SS +ve PTB
• Grading of smears in helpful as a quality assurance tool

universal Drug Susceptibility Testing (uDST)

• UDST for all notified TB patients (bacteriologically formed & clinically diagnosed)
• All TB patients are offered DST to at least the rifampicin through rapid molecular test
• Cascading DST for fluorouridines & second line injectable are offered through LPA

Case definitions
Micro biologically confirmed TB
Presumptive TB patent with biological specimen positive for AFB, or positive for MTB on culture (or) positive
for TB through quality Assured Rapid Diagnostic molecular test.

Clinically diagnosed TB case

• A presumptive TB patient who is not microbiologically confirmed, but diagnosed with active TB by a
clinician confirmed, but diagnosed with active TB by a clinician on the basis of X-ray, Histopathology (or)
clinical signs with a decision to treat the patient with a full course of ATT
• In children, this is based on the presence of abnormalities consistent with TB (or) Radiography, History
of exposure to an infectious case / Evidence of TB infection (TST+) &clinical findings suggestive of TB in
the event of negative / unavailable microbiological results.
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PSM

Sub Bacillary Population

Fig. 8 : Bacillary population

Sterilizing Prevention of Emergence of

Drugs Early Bactericidal activity resistance
Isoniazid ++++ ++ +++
Rifampicin +++ ++++ +++
Streptomycin +++ - ++
Pyrazinamide ++ +++ +
Ethambutol + - ++

TB treatment:
Type of TB case Treatment Regimen in IP Treatment regimen in CP
Now & previously 2 HRZE 4 HRE
treated cases

IP CP
DOSES DOSES
56 112

NIKSHAY
Patient, flow in Nishay
Nishay 1 Initiating Patient on appropriate treatment
Nishay 2 Transfer / Referral flow after initiation of treatment
Nishay 3 Nishay Aashaadha

NSP 2017-25 HAS BEEN REPlACED BY NSP 2020-25

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NPEP, NHM

NPEP [NatioNal Polio ElimiNatioN ProgrammE]

Diagnosis
• Stool culture &Viral isolation
• Part of AFP Surveillance [Acute Flaccid Paralysis] → Acute →<4wks
SMO (Surveillance Mo) - min - MBBS
↓
House of Suspected case
↓
Collects Stool sample
↓
Reverse cold chain [+2+8°]
↓
Lab
• Age group → 0-15 yrs → 2 stool samples 24-48 hrs apart
Each ~ 8 gm [Adult thumb size] < 14 days of onset
Reverse cold chain
> 60days follow up visit for residual paralysis < 90 days diagnosis of Polio to be confirmed

aFP SUrVEillaNCE – iNDiCator

2 Gold Standard I’s
1. Non-polio AFP Rate ≥ 2/1,00,000 children
2. Stool Specimen (2) collection ≥ 80%

timeliness indicators
• AFP cases investigated < 48 hr.
• adequate stool specimen
• Specimens arrive in lab in good condition ≥80%
• Specimen arrive in WHO lab < 3 days
• Specimen with lab result < 28 days

Pulse polio 1995-96 → Each child 2 drops of OPV to all <5y of same age
Intensified Pulse Polio → House to House survey after PP Day
SWitCH → t OPV (P1P2P3) → b OPV (P1P3 )
National SWitCH DaY → 25th April 2016
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PSM

Polio EraDiCatioN StratEgiES

1. Routine Immunisation – OPV & IPV
2. Pulse Polio – NID/SNID
3. AFP Surveillance
4. HTH Coverage – Mopping up

NHm 2013
NHRM [National Rural Health Mission] [2005-12]
NUHM [National urban Health Mission] [2005-12]
→ NHM 2013includes RCH, NVBDCP, RNTCP, NLEP, IDSP - Comm. diseases coverage
NPCB, NIDDCP, NPCDS, NMHP, NCD coverage
NTCP, NPHCE, NPOH, NPPCF

• Major Targets
1. MMR → <1/1000 [100/1, 00,000]
2. IMR → < 25/1000
3. TFR → 2.1

Fig. 1: NHm
• Components [RMNCH + A Strategy]
RBSK, RKSK, NSSK, JSSK, IMNCI, Immunization, Diarrhea control,
ARI / Pneumonia, Family planning

JSSK [Janani Shishu Suraksha Karyakram]

→ NMBS [National Maternal Benefit Scheme 1961] → JSY [Janani Suraksha Yojana]
[12 April 2005]
↓
JSSK
[01 June 2011]
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NPEP, NHM

Beneficiaries
Maternal component New Born component

Free delivery Free drugs

Free drugs Free diagnostics

Free Diagnostics Free blood transfusion

Free Diet[3D-Normal vag. delivery] NB Care Corner [NBCC]

[7D-Cessarian delivery] NB Stabilization Unit [NBSU]

Free Transport Specialized NB Care Unit [SNCU]

Facility based integrated Mx of childhood illness [F-IMNCI]]
Nutritional Rehabilitation center NRC Home Based New Born
Free Blood Transfusion care HBNC

NBCC NBSU SNCU

MCH level I II III

Location PHC CHC DH

Care NB care Sick + LBW Sick

Staff 1 Doc + 1 Nurse 1D+4N 1 Pead, 2-3D + 10-12N

Beds 0 04 12-20

Training NSSK F-IMNCI FBNC

NSSK - Navjat Sishu Suraksha Karyakram, FBNC - Facility Based NB care

RCH Programme 1997

• Strategy → RMNCH + A
R -Reproductive Health → RTI/STI
MN -Maternal & NB Health → JSSK
CH -Child Health → RBSK
A -Adolescence → RKSK

rBSK [rastriya Bal Swasthya Karyakram]

• Beneficiary → Child [0-18 yrs]
0 - 6yr [Rural + Urban Slums]
6-18 yr [Government Schools]
• 30 Disorders
Diseases
4D’s Deficiencies
Defects
Development Delays with Disabilities
• Mobile Health Team → 2 AYUSH MO’s, 1 ANM, Pharmacist
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PSM

rKSK [rastriya Kishor Swasthya Karyakram]

• Beneficiary → Adolescent (10-19 yr)
• Components (7C’s)
Clinic
Community
Communication
Content
Convergence
Coverage
Counselling

NrC [Nutritional rehabilitation center]

• Beneficiary → SAM < 5 Year aged children
• Stabilization Phase → 1-2 Days [Starter diet]
• Transition Phase 2-3 Days [Catch-up diet]
• Rehabilitation Phase → Vitamin A, Zinc, Copper, Multivitamins, Iron, Folic Acid

NSSK [Navjat Shishu Suraksha Karyakram]

• Beneficiary → Early Neonate
• Training programme for all levels of HC personnel on NB care & Resuscitation

imNCi [integrated management of NN & Childhood illness]

• Components Diarrhea Pneumonia Measles PEM Malaria
• Beneficiaries < 5yr, (< 2months, 2m – 5yrs)
• Management
Assess
classify the illness
Identify the R,
Treatment
Counsel the mother
Give follow up care

HBNC [Home Based New Born Care]

• PN visits By ASHA
6 in Institutional Deliveries on DAY 3 7 14 21 28 42
7 in Home Deliveries on DAY 1 3 7 14 21 28 42

rCH also covers

Immunization
Diarrhea
ARI /Pneumonia
Family Planning
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NPCBVI, NACP

NPCBVI
[National Programme of Control Of Blindness & Visual Impairment]
Blindness → <3/60 in BEBPC
Causes → MC - Cataract (62%)
RE (19.7%)
Prevalence → 0.36%(2019-20)

Fig. 1: NPCBVI
• If blind school survey used, then estimation of total Blindness in India is Gross under estimation

VISION 2020
Main AIM → To eliminates all causes of Avoidable Blindness
1. Preventable
• Vit A Def.
2. Curable
• Cataract
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PSM

GLOBAL INDIA
1. Cataract 1. Cataract
2. RE + low vision 2. RE + low vision
3. Childhood Blindness 3. Childhood Blindness
4. Trachoma 4. Trachoma
5. Onchocerciasis /River blindness 5. Diabetic Retinopathy
[Not present in India] 6. Glaucoma
No vector 7. Corneal blindness

Rajendra Prasad Institute of Ophthalmic Sciences, AIIMS, Delhi (APEX)

NUMBERS Population Norms

2 Apex centres 1/500m

20 COE 1/50m

200 Training centres 1/5 million

2000 Service centres 1/500000

20000 Vision centres 1/50000

Fig. 2: Vision 2020

Services offered at By
Vision center → Vision testing → PMOA [Paramedic Ophthalmic Assistant]
Service center → Cataract Six → Ophthalmologist
Training cente → Training → Ophthal Department of Medical College

School vision Screening Programme

• I Teacher / 150students
• V-VIII (10-14 yrs)
• Refer to PMOA, PHC [min. pre requisite]
• VA cut OFF for referral → <6/9
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NPCBVI, NACP

NACP, 1987 [NAtIONAL AIDS CONtROL PROGRAMME]

Background → 1st case 1986 Chennai
Launched NACP, 1987 [Phase 1, 1992]
NACP 4th phase (2012-17) → To Accelerate, reverse & integrate response
Objectives → 1. Reduce new infection by 50% (2007)
2. Provide comprehensive care to all PLHA
[People living with HIV AIDS] & R1 services for all who require
Screening → ERS Battery 1 out of 3 → before blood Transfusion ELISA, 2 out of 3 → Symptomatic for
HIV, Rapid All 3→ Asymptomatic for HIV Simple
Diagnosis → Western Blot Assay Based on P24, gp 41
P24 Ag test
NA Base test
RT PCR test
Quantiplex br. DNA test

Fig. 3: HIV / AIDS

ICTC [Integrated Counselling & Testing Centre]

Components
• VCTC – Pre Test C, Post Test C, Follow up C
• PPTCT
types – Fixed facility & Mobile
Staff – Manager, Counseller, Outreach W, Lab T

types of tEStING
OPt-in testing – patient offered testing & patient give permission actively
OPt-out teasting – Testing is Performed after Notifying (INDIA) Informed Consent
targeted → CSW MSMs [Men having Sex with Men], Street Children
Interventions IDU Migrant laborer Adolescents
Truck Drivers Trans genders

MtCt/PtCt HIV
• Rate of MTCT HIV in India → 30%
• Rate of MTCT through Breast feed 12-16%
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PSM

• Prevention of MTCT

Efficacy

1. Zidovudine > 66% Best

2. Nevirapine > 50% MC used → Single Oral Dose

3. Elective CS > 50%

Nevirapine single oral Dose

Mother New Born

20 mg at onset of labor Dose - 2mg/Kg oral suspension < 72 hr.

• Post NVP Prophylaxis MTCT Rate will become → 30% to 15%

4. Current modality of choice → Triple ARV Prophylaxis [>90% efficacy]
• Tenofovir
NNRTI/Efavirenz
• Lamivudine Lopinavir / Ritonavir Substitution
Earlier in life
• Efavirenz
• Started from 14wks POG
Pregnancy
Labour delivery
Breast feeding till 1 wk. post BF stoppage
NVP Prophylaxis to New Born 0-6 Wks age

ARt
• LAC (Link Art Centre)
Drugs, S/E Mgt, T/t OI, Monitoring of Reinforcement

• LAC PLUS (LAC + PREART Mgt)

Integrate HIV into general H. care
Decrease loss of patients from ICTC – Case & S

PEP [Post Exposure Prophylaxis]

• Preferably with …2hr.
• Maximum within…72 hr.
• Duration of Px…28 days

>10 y
ADOLEESCENTS ADULTS Lamivudine + Tenofovir + Dolutegravir
>30 Kg

>6 y
CHILDREN Lamivudine + Zidovudine + Dolutegravir
>20 Kg

<6 y
CHILDREN Lamivudine + Zidovudine + Lopinavir/Ritonavir
<20 Kg
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NPCBVI, NACP

ALL-IN INItIAtIVE (UNAIDS & UNICEF)

Global Initiative to End Adolescent AIDS

GOALS
1. End adolecents AIDS by 2030
2. End HIV Epidemic as a PH Threat

TARGETS
1. Reduce new HIV by 75%
2. Reduce HIV death by 65%
3. Achieve ZERO Discrimination
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NVBDCP, NLEP

NVBDCP [National Vector Borne Disease Control Programme, 2003-04]

• MC VBD → Malaria
MC Viral VBD → Dengue
MC Arboviral VBD → Dengue
• 1 Malaria 4 Kala Azar
2 Filariasis 5 JE
3 Dengue 6 CGF

Fig. 1: NVBDCP

MALARIA
Diagnosis
1. PBS [ JSB , Jaswant Singh Bhattacharya Stain]
2. Dip Stick Test [Rapid Diagnostic kit test] based on Pf histidine Rich protein Type 2
3. Optimal Test
• 1 microscopy /25000 POP

ITBN
• Insecticide Rx Bed Nets
• Shelf life - 6months
• 2.5% Deltamethrin [25mg/m2]
5% Cyfluthrin[50mg/m2]

LLIN
• Long lasting Insecticide Rx Bed nets
• Shelf life - 3 yrs
• Use chemical binder
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PSM

Treatment [2013]
CASES
P. Vivax P. Ovale P.Fal. P. Malariae

Chloroquine + Primaquine ACT + Primaquine

Other parts of India North East India

ACT - SP + PQ ACT - LM + PQ
A = Artesunate A =Artemether
S = Sulfodoxime LM = Lumefantrine
P = Pyrimethamine
• Pregnant cases (All treatments same except)
– PQ withdrawn
– 1st Trimester Quinine > ACT
Chemoprophylaxis
Short term [≤6 wks] – Doxycycline [1 days before 4 wks after return]
Long term [>6 wks] – Mefloquine [2 wks before & 4 wks after return]

Malariometric Measures
OLD
• Spleen rate - Endemicity
• Infant parasite rate - Recent transmission

NEW
• Annual Parasitic Incidence [API] - Best indicator of malaria control
• Annual Blood Examination Rates - Best indicator of operational efficiency
• Slide Positivity Rate
• Slide Falciparum Rate

FTD VS DDC
Fever T/t Depot Drug Distribution C
PBS ü û
Treatment ü ü
Bed net impregnation ü ü
Larvivourous fishes ü ü

Modified Plan of Operation (MPO, 1977)

• API ≥ 2 – Regular Spray
• API < 2 – Focal Spray
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NVBDCP, NLEP

Chemical Spray g/m² Rounds

DDT 1 2
Malathion 2 3
Pyrethrum 0.25 2

ROLL BACK MALARIA – 1998-99

• By WHO, UNICEF, UNDP, WORLD BANK
• ITBN + Drugs + Vaccines

EMCP (Enhanced Malaria Control Project)

1. API> 2
2. PF cases > 30%
3. Tribal > 25%
4. Reports of death

National Framework For Malaria Elimination

• Eliminate by 2022 from LOW/MOD. Risk
• Reduce incidence < 1/1000 by 2024
• Interrupt transmission by 2027
• Prevent Re-establishment of Transmission

KALA AZAR
Treatment
1 LAMB → 10 MG/kg/b.wt Liposomal Amphotericin B
2 MILTEFOSINE + PARAMOMYCIN
3 Amphotericin B emulsion
4 Miltefosine capsule
5 Amphotericin B Deoxycholate
6 Amphotericin B emulsion injection

NLEP [National Leprosy Eradication Programme]

Fig. 2 : NLEP
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PSM

Multi Drug Therapy (MDT)

PBL [Paucibacillary] MBL [Multi Bacillary]

No. of skin lessons • ≤5 >5
≥ 1 N MC - Ulnar nerve Test at Medial
Nerve involvement • 0–1 Condyle Check for cord thickness
RJC • TT,BT BB, BL, LL
No. of Drugs • 2 Dapsone Rifampicin 3 Dapsone Rifampicin Clofazimine
Duration of Rx • 6m 12 m
Duration of follow up • 2 yrs 5 yrs

• MDT completed, no change in lesions → Stop MDT Reassure

[Bacteriological recovery do not coincide with clinical Recovery]
• OAMS [Once A Month Supervised Therapy]
• Accompanied MDT
– Any responsible person can collect MDT therapy on behalf of patient
• Uniform MDD
– Dapsone + Rifampicin + Clofazimine to all
• SET center → Survey Education & Rx center
SIS → Simplified Information System

PEP [POST EXPOSURE Px]

DORS (Direct Observed Rifampicin Supervised)
Inclusion criteria: > 3 months, 20h/week (1 year) ; for AGE ≥ 2 years

Exclusions
TB Acute Febrile Illness
Leprosy Renal Disorders
Pregnancy Liver Disorders
RIF in Last 2 years

Rifampicin Dose:
• Single dose

> 35 Kg 600 mg
20-35 Kg 450 mg
< 20 Kg 10-15 mg/Kg
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Other and New Programs

NatioNal iodiNe deficieNcy disorders coNtrol Programme

[NiddcP],
National Goiter Control Programme, 1962 → NIDDCP, 1992
Impact Indicators →
• Major→ UIE [urinary Iodine Excretion] levels generally measured in Pregnant female over 24hrs
• Others → Neonatal hypothyroidism, Goitre
Level of Salt Iodination → 30 ppm at production level
15 ppm at consumer level
Two-in-one salt → 40 µg Iodine + 1 mg Iron/gm of Salt
Criteria to track Elimination → 1 Enlarged thyroid (6 - 12y)→<5%
2 UIE <100 mcg/L → <50%
3 UIE <50 mcg/L → <20%
4 House hold’s with iodized Salt → >90%

iNtegrated disease sUrVeillaNce ProJect (idsP)

• Encompasses

regular surveillance sentinel surveillance Periodic surveillance

VBD (Malaria) HIV NCD Risk factors with
WBD (Typhoid, Cholera) HBV Anthropometry
RD (TB) HCV BP
VPD (Measles) Water quality Tobacco
Polio Air Quality Nutritional Status
RTAs
Blindness
YF, Plague
Meningitis
Haem . Fever

Resp. Distress
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PSM

Fig. 1 : IDSP
• Forms under IDSP
S form → Suspected cases → by health workers Syndromic Dx
P form → Presumptive cases Doctor/med.officer→ Presumptive Dx
L form → Lab confirmed cases→ Lab staff→ Confirmed Dx

NPcdcs
1. subcentre
• H. Promotion
• Opportunistic Screening – BP, Blood Sugar, > 30 years
• Referral to CHC – if DM, HTN

2. cHc

Fig. 2 : NPCDCS
• Diagnosis and Mx at NCD clinics
• Home Visits by Nurses in c/o Bedridden
• Referral to DH if complication presents

3. dH
• H. Promotion
• Screening for > 30 years
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Other and New Programs

• Diagnosis & Mx of CVD

• Home based Palliative care

4. Urban H. checkup scheme

• Slum
• Age > 30 years
• Pregnant female

5. cancer control
• Regional CC scheme
• Oncology Wing Dev Scheme
• Decentralised NGO
• IEC
• Research & Training

NPPcd
• National Programe for Prevention & Control of Deafness
• Reduce disease burden by 25% (XI FYP)

NPPcf
• National Programe for Prevention & Control of Fluorosis
• SUSPECT CASE
1. Dental – white spots/ Y. streaks
2. Skeletal – pain, bow legs, squat
3. Non-skeletal fluorosis – GIT, Neurolg., MS
• Confirmed case –
1. Urine fluoride level > 1mg/L
2. Serum fluoride
3. IO membrane calcification

ayUsHmaN BHarat scHeme [aBs], 2018

Health& Wellness centres [Hwc]
• 1.5 Lac HWC centers
• comprehensive health care [including MCH, NCDs]
• Free essential drugs & diagnostic services

National Health Protection scheme [aB-NHPs] / Pradhan mantri Jan aarogya

yojana [PmJay]
• target →10.74 crore families, Total 50 crore people]
• apex → Chaired by Union Health & family welfare Minister
• defined Benefit cover
– Rs 5 lakh/family/year; No cap on family size & age
– Secondary & Tertiary care hospitalization
– Cashless & Paperless Scheme
– Public hospitals& empaneled private hospitals
– Include 1354 packages
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PSM

[Including Bypass, Stenting, Knee replacements]

– Hospital eligibility
– All public hospital
– Empaneled private health care facilities
– Empanelment criteria for Hospitals with > 10 beds

anemia mukt Bharat [amB] / intensified iron Plus initiative 2018

• MAIN AIM → to reduce prevalence of anemia by 3% points per year among children, adolescent and
women in the reproductive age group [15-49 yrs], b/w the year 2018-22
• ANEMIA MUKT BHARAT 6X6X6 Strategy
– 6 Beneficiaries
– 6 Mechanism
– 6 Interventions
• PROPHYLACTIC DOSE & REGIME FOR IRON FOLIC ACID SUPPLEMENTATION

age groUP elemeNtal iroN [mg] folic acid [mg] frequency remarks

6-59 months 20 100 Biweekly Bottle [50 ml]

5-9 years 45 400 Weekly Pink color tablet

10-19 60 500 Weekly Blue color tablet

20-49 years 60 500 Weekly Red color tablet

Pregnant Lactation 60 500 Daily Red color tablet

sWacHH BHarat missioN [sBm] 2014 / sWacHH BHarat aBHiyaN 00

aim : To eradicate/end open- defecation in India by 2019 by construction of 12 million toilets

swachh Bharat mission - gramin [sBm-g]

• Construction of toilets in Government schools [Ministry of Human Resource & Development]
• Rural School Sanitation → Separate Boys/Girls toilets [Dept. of School Education]
• Construction of toilets in Anganwadi centers [Ministry of women & child development]

swachh Bharat mission - Urban [sBm-U]

• Household toilets [and conversion of insanitary latrines to pour - F lush latrines, community toy lets solid
waste e management, IEC & Public awareness, capacity building
• Implementation by → Ministry of Urban development

NatioNal NUtritioN missioN [NNm] 2017-18/PosHaN aBHiyaN

VISION → To ensure attainment of Malnutrition - Free India by 2022

targets
• To reduce stunting, under nutrition, anemia [among young children, women & adolescent girls] & reduce
Low Birth Weight by 2%, 2%, 3% and 2% per annum respectively
• Achieve reduction in stunting from 38.4 % [NFHS-4] to 25% by 2022 [Mission 25 by 2022]
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Other and New Programs

NatioNal digital HealtH missioN 2020 (NdHm)

Formulated by MOHFW, GOI

AIM:
To provide necessary support for ‘integration of Digital Health Infrastructure’ in India

Basis:
National Health Policy-2017
NHA- National Health Authority
“Universal Health Coverage”

fig. 1: NdHm

NdHm ecosystem:
– NDHM will overall monitored by MOHFW under Ministry of Electronics & Information Technology
– This initiative is taken under by Digital India and the Data Govt. in will be responsible for maintaining
and updating the resources

fig. 2: NdHm
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PSM

Key features
• Health ID:
– Unique for every citizen of India
– It has all the Health related information of the individual
– Various healthcare providers like hospitals, laboratory, insurance firms, telemedicine firms, online
pharmacies is included
– This health ID once generated will be linked to mobile number & AADHAR
– This will be voluntary basis
• Personal heal record:
– Electronic record managed / shared by the individual itself
• Digi doctor
– A comprehensive repository of all doctor’s who are practicing modern allopathic system
– Enrollment of doctors is voluntary
• Health Facility Registry:
– It’s complete repository of all the facilities across the country
– It includes both Government Public & Private Hospitals, Pharmacies, Laboratories, Clinics & Imaging
Centers
• Electronic Medical Records:
– Where are the health care related information will be linked to the Health ID of the individual
– In future E-Pharmacy, telemedicine services will be added to this.

iNtegrated cHild deVeloPmeNt serVices (icds) 1975

[rural areas & Urban slums]
Heart of ICDS → Anganwadi
Population Norms → 1 AW/400-800 in plains
1 AW/300-800 in hills

Fig . 3: ICDS

Beneficiaries→
1. Children [0-6 yrs]
2. Pregnant & lactating female
3 Non Pregnant Non Lactating Reproductive age 15-49y female
4. Adolescent Girls (11-18 yrs)

services → Health Education

Immunization
Family Planning & contraceptive
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Other and New Programs

Referral Services
Non formal Pre School education
Health Check ups
Free food supplementations

free food → calories(1/3) Proteins (1/2)

supplementation 500 K.cal 12-15 gms 6-72 m children
800 K.cal 20-25 gms Malnourished children
600 K.cal 18-20 gms Preg & Lactating Mothers
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Health Schemes, Strategies, Initiatives, Policies &

Legislations

MID DAY MEAL PROGRAMME / MID DAY MEAL SCHEME

(1/3) Calories Proteins (1/2) Cereals

Primary → 450 K.cal 12 gm 100 gms

Upper Primary → 700 K.cal 20 gm 150 gms

Ministry → Human Resource & Development

Fig. 1: MDMP

NAtIONAL PROGRAMME FOR PREvENtION & CONtROL OF DIAbEtES, Cv

DISEASES &StROkE (NPCDCS)
• launched in 100 districts & 21 States
1. Sub center → Health promotion
Opportunity Screening for BP & Sugar Referral to CHC for DM, HTN
2. CHC → Diagnosis & Management at NCD clinics Home visits for bed ridden patients Referral to DH if
complicated cases
3. DH → Health Promotion Screening for > 30 yrs. Dx & Mx of CV diseases Palliative Care for Chronic
Debilitating Progressive Patients
4. Urban Health Checkup scheme → Screening of urban slum Population
→ Screening for population >30yr Pregnant Female
5. Cancer control → RCC OWDS
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PSM

SUMAN

Fig. 1: (Surakshit Matritva Aashwasan) Launched on 10 October 2019

Goal: To end all Maternal & new born deaths
vision: Achieve ‘zero’ maternal & new born deaths Through quality care with dignity & respect

beneficiaries
• All Pregnant Mothers
• All mothers up to 6 months post delivery
• All sick newborns

SUMAN SERvICE GUARANtEE

1. basic Package
• Health & Wellness Center- Sub health center / HWC-Primary Health Center
• Primary health Center / Urban Primary Health Center

New born care corner (NbCC)

• Pregnancy testing kits
• Routine ANC, PNC, Complications
• Minimum 4 Antenatal checkups, 1 Pradhan Mantri Surakshit Matritava Abhiyan (PMSMA) referral
• Complete, comprehensive Antenatal care
• Breast examination
• HIV, Syphilis identification
• Reproductive tract infection / sexually transmitted infection managements
• Skilled Birth Attendants
• Referral & pre referral management of Obstetric complications
• Family planning counselling
• Provisions for contraceptives
• Follow up care

2. bemonc Package
• Non FRU Community Health Centers
• Urban community health centers
• Sub district hospitals & other Hospitals
New born Stabilization unit (NbSU)
• “Basic Package” (+) plus
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Health Schemes, Strategies, Initiatives, Policies & Legislations
• Assisted Delivery
• Management of complications, referral to comprehensive Emergency Obstetric & Neonatal Care (CEmONC)
• Stabilization of Obstetric complications
• Episiotomy Suturing
• Antibiotics
• Breast feeding & Kangaroo Mother care
• Past natal package + 48 h stay
• Sterilization
• Safe abortion
• New born sepsis management
• Photo therapy management
• Diarrhoea / Pneumonia

3. CEmONC package
• Medical colleges
• District Hospitals
• Sub District hospitals
• FRU- Community Health Center
• Urban Community Health Center

bEmONC Package +
• Identification, screening & testing for elimination of Mother to child transmission of HIV & Syphilis
• Delivery of HIV+ women
• Link ART
• Obstetric emergencies
• Cesarean section
• Blood Bank
• Surgical methods for Abortion
• NQAS (National Quality Assurance Certified),
• Lashay A centers also included in BEMONC, CEMONC

PRADHAN MANtRI SURAkSHIt MAtRItAvA AbHIYAN (PMSMA)

• To provide quality Antenatal care services for 2nd (or)3rd trimester on 9th Date of Every Month
• PMSMA clinics consists of Private Practitioners
• All the investigations will be done before seeing the obstetrician
• The Obstetrician will do the complete examination
• This scheme is under MOHFW
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PSM

Fig. 2: PMSMA

Rural Areas Urban Areas

PHC Urban dispensary

CHC Urban H posts

Rural Hospitals Maternity Homes

SDH

District Hospitals

Medical Colleges

PMMvY (Pradhan Mantri Matru vandana Yojana)

• Rs. 5000/- incentive – pregnant/lactating female (3 installments)
• ≥ 19 yr. at 1st CB

First Registration OF PREGNANCY 1000/-

Second First ANC visit 2000/-

Third CB registration with BCG, OPV, DPT & Hep B 2000/-

DAkSHtA 2015:
• To empower providers for improved maternal & neonatal health care during institutional deliveries
• AIM – To reduce Maternal & neonatal Mortality
• This is being implemented on 98 districts of Madhya Pradesh Maharashtra Odisha Andhra Pradesh
Jharkhand Telangana

4 Pause Points has been identified

1. At the time of admission
2. Before pushing or CS
3. Soon after delivery (1hr)
4. After discharge

target population
– Medical officers
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Health Schemes, Strategies, Initiatives, Policies & Legislations

– Nurses
– Auxiliary Nurse Midwife

SAANS:
Social Awareness & Action Plan to Neutralize Pneumonia Successfully

<3/1000 Live Birth by 2025

Fig. 3:SAANS

Objectives:
– Awareness in community
– Awareness of care gives to identify early
– Dispels myths & notions & trigger behavior change

tARGEt bENEFICIARIES:

All care givers

Primary Mothers Community Mobilization
Fathers

Secondary
• Gram Panchayat Leaders
• Local Administration
• Religious Leaders
– Village Health Sanitation & Nutrition Committee Members
– ICDS
– Private practitioners
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PSM

Strengthen Facilities:
• Availability of Amoxycillin dispersible tablets
• In patient care for severe cases
– O2
– Pulse Oximeter
– Antibiotics
ƒ Standard treatment protocols
ƒ SAANS Booth

JANANI SHISHU SURkSHA kARYAkRAM: (JSSk)

Dietary Norms
Free diet
Vaginal deliver 3days
Caesarean Section 7 days

RDA Requirements according to 2010 Nutrition guidelines

Pregnancy Lactation

Energy 2250 kcal/day 2500 kcal/day

Proteins 78 grams/day 74 grams/day

Fats 30 grams/day 30 grams/day

Calcium 1200 mg/day 1200 mg/day

Iron 35 mg/day 21 mg/day

Diet Guidelines for vaginal delivery

• Normal diet x 3 times a day
• Consume within 2 hours of cooking
• High energy snacks
• Iodized salt (15ppm at CL)
• ≥2L water / day

Diet Guidelines for C-section delivery

– > 6h of surgery, sips of water Day-1 Liquid diet
Day-2 Soft diet (should be consulted with attending physician before initiation) Khichdi, Upma, Poha,
Dalia
After 2-3 days- Normal Balanced diet
2-3 L fluids / day

Arogya Satu
• “Mobile Application” to spread awareness for COVID-19 among citizens of India
• This replaces the App “CORONA-kAvACH”
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Health Schemes, Strategies, Initiatives, Policies & Legislations

Fig. 4: Aarogya Setu

The main functions include
1. Contact tracing
2. Syndromic Mapping
3. Self-Assessment
– It also tell you about total no. of affected people in a given area

National Medical Commission (NMC)

IMC ACT 1956 (MCI Medical council of India)

↓ BOGMCI

NMC ACT 2019 ↓

Aug 8, 2019 NMC

Consists of 4 Autonomous bodies

1. Under Graduate Medical Education
2. Post Graduate Medical Education
3. Medical Assessment & Rating
4. Ethics & Medical Registration
Common final year MBBS professional exam is being planned where the professional Exam will be replaced by
NEXT (National Exit Exam)

NEXT

Licensure Criteria for entering post

Exam graduation along with foreign
medical graduate exam

PMMSSY 2006 [PRADHAN MANtRI ‘SWAStHYA SURAkSHA YOJANA]

• Correction in imbalances in availability of affordable Health care in country
• Components
– Opening up of AIIMS like institutions across country
– Upgradation of Medical colleges & institution in India
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PSM

PMJDY [PRADHAN MANtRI JAN DHAN YOJANA]

• National mission for financial inclusion
• Launched on 15th August 2014

MtP ACt 1971

Indications
• Humanitarian
Eugenic
Therapeutic
Social
Education Qualifications → MD Gyn obs, Diploma Gyn obs, MBBS + 6m Jrship in Department of Gyn Obs
Experience →≥ 25 MTP’s
timing → 0-20 wks→ [Low risk]- 1 Doctors opinion
→ 20-24 wks [High risk]-2 Doctors opinions

ORGAN tRANSPLANtAtION ACt, 1994

• Any person ≥18 yrs can authorize
• Only for therapeutic purpose
• 2011 onwards 10 yrs imprisonment + 20 lakh to 1 crore fine [High risk]

NAtIONAL RURAL EMPLOYMENt GUARANtEE ACt 2005 (NREGA)

• > 100 days of employment/year → Job card given
• < 15 days → employment → < 5 km Radius of house
• Unskilled manual labor work → Standard wages
• BPL Families

Fig. 1: NREGA
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Health Schemes, Strategies, Initiatives, Policies & Legislations

NHP (NAtIONAL HEALtH POLICY 2017)

GOALS for

YEAR MISSIONS

2017 Elimination of Kala azar

Elimination of L. Filariasis

2018 Elimination of Leprosy

2019 IMR 28

2020 MMR 100

UNAIDS HIV target 90-90-90
Decrease Agriculture injuries by 50%
Access to Safe WS & Sanitation
Increase State H. Sector Spending > 8% of BUDGET
Decrease Tobacco use by 15%

2022 Establish DALY as measure of Disease Burden

2025 Increase utilization of PH facilities by 50%

Decrease mortality from CVD, Cancer, DM, RD by 25%
ANC coverage > 90%
Primary I. coverage > 90%
90% met need of FAMILY Planning
80% HTN/DM controlled status
Stunting decrease by 40%
H. Expenditure as % GDP from 1.15% to 2.5%

PCPNDt ACt, 1994

– PreConception PreNatal Diagnostic Techniques act
ƒ Prohibition of SEX selection
ƒ Punishment – 3 years Imprisonment + fine (Rs. 10,000)
ƒ Repeat - 5 years Imprisonment + fine (Rs. 50,000)

NDPS ACt, 1985

– Narcotic Drugs and Psychotropic Substances act
ƒ Narcotics, PS – 10-20 yr. I. + 1-2Lac fine
ƒ Ganja – 5 yr. I + 50,000 fine
ƒ Users not covered under section 15-25 – Treatment + Rehabilitation
ƒ Personal Consumption – 6 months I. + fine
ƒ Alcohol use is not covered

COPRA ACt, 1986

– COnsumer PRotection Act
– Dispute Redressal Committee
ƒ National - > 1 crore
ƒ State – 20 Lacs – 1 crore
ƒ District - < 20 Lacs
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DEMOGRAPHY
Definitions and Concepts

Demography: Scientific study of human population

1. Size
2. Composition
3. Distribution

5 DEMOGRAPHIC PROCESSES
FERTILITY
MARRIAGE
MORTALITY
MIGRATION
SOCIAL MOBILITY

Total no. of Births

CRUDE BIRTH RATE [CBR] → × 1000 → India - 19.5
Total mid yr population

Total no.of Death

CRUDE DEATH RATE [CDR] → × 1000 → India - 6.0
Total mid yr population

Growth Rate [GR] → CBR-CDR = DEMOGRAPHIC GAP

DEMOGRAPHIC CYCLE
CBR CDR
1. High stationary stage high high
2. Early Expanding stage high Starts ↓
3. Late Expanding stage Starts ↓ Already↓
4. Low stationary stage Low Low
5. Declining stage CDR more than CBR
→ India currently in stage III

Fig. 1:
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PSM

Fig. 2: Demographic cycle

DEMOGRAPHIC GAP
1. Maximum DG → Late stage II
2. DG Starts contraction → Early stage III
3. Minimum DG → Stage I & IV
4. Negative DG → Stage V
Demographic Transition -In Economic development, movement from HIGH CBR/CDR to LOW CBR/CDR.

Population Pyramid
[AGE-SEX PYRAMID]
RIGHT SIDE – FEMALE
LEFT SIDE – MALE
X-AXIS – POPULATION IN %
Y-AXIS – AGE (IN CONTINUOUS INTERVALS)
TYPE – DOUBLE HISTOGRAM

Fig. 3: Population Pyramid

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Demography Definitions and Concepts

DEVELOPING COUNTRY DEVELOPED COUNTRY

Fig. 4 : Shape of population pyramid

PARAMETER DEVELOPING COUNTRY DEVELOPED COUNTRY

SHAPE FERTILITY UPRIGHT TRIANGLE SPINDLE SHAPE

PATTTERN [NARROW TOP [BULGE IN MIDDLE]
BROAD BASE]

SPAN LIFE SHORTER TALLER

EXPECTANCY

SYMMETRY SEX RATIO ASYMMETRIC SYMMETRIC

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Data Collection Systems & Indicators

DEMOGRAPHIC FERTILITY INDICATORS

TFR [Total fertility Rate] → otal no. of children born to a woman → completed family size
GFR [Gross Reproduction Rate] → Total no. of Girl children born to a woman
NRR [Net Reproduction Rate] → Total no of Girl children born to a woman taking into account
their mortality

Q If TFR ~ 4, GRR ~ ? → 2 [GRR or NRR ~ 1/2 TFR]

→ GRR or NRR ~ 1/2 TFR

Q If TFR = 2.2, CBR ~ ?

→ CBR = [8TFR] + 1

= 18.6 per 1000 MYP

• Goal of TFR 2.1 by 2017 (current TFR → 2.0)

• Goal of NRR 1 by 2017
To achieve NRR 1 → CPR > 60%
To achieve NRR 1, Ideal contraception Sterilization [vasectomy]

Total Lives Births

GFR [General fertility Rate] → × 1000
Total women (15-49 yr)

Total live birth (0-4 yrs)

CWR [child women Ratio] → × 1000
Total women (15-49 yr)

< 15y + > 65 yrs (Non earning)

DR [Economic Dependency Ratio] →
15-65 yrs (earning)

Q. 0-15yrs - 30%
>65yrs - 10%
DR?
30% + 10% 66
= 0.66 =
60% 100
→ 66 non earning population dependent on 100 earning population OR 100 Earning population is supporting total
of (100+66) 166 Population
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PSM

CENSUS, SRS, NFHS, DLHS, VRS

Census
Once every → 10 yrs [last @ 2011]

First census → 1871 [15 till now]

First Disability census → 1881

Census stop → 01 March 00.00 Hrs.

Big Indian divide → Census of 1921

Fig. 1 : Big Indian Divide

• Ministry → Home Affairs
• New inclusions in census 2011
1. 10 finger prints
2. Iris scan
3. Photography
4. UID [Aadhar No.]
5. NRC [National Register for citizen]

Sex Ratio
No. of females
→ SR = x 1000
No. of males
• SR India → 943F/1000M [due to female infanticides] Highest → Kerala → 1084
Lowest → Daman & Diu 618
Q Total population
M:F→ 3:2, SR → ?
2x
= x1000
3x
= 666.6/1000M
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Data Collection Systems & Indicators

Fig. 2: Sex ratio

Child Sex Ratio

Females (0-6y)
CSR x1000
Males (0-6y)

→ CSR India → 919

→ Highest → Mizoram
→ Lowest → Haryana

Fig. 3 : SR, CSR

Literacy Rate
Total No. of Literates x 100
→ → Proportion
Total pop. aged 7y and above

M - 82% [4/5th]
→ LR india → 74% [3/4th]
F - 65% [2/3rd]
→ Highest → Kerala
Lowest → Bihar
→ Literate → Read, write & understand any 1 language [>/ 7yr age]
→ LR used in → PQLI, HDI, HPI-1
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PSM

Growth Rate
→ Decadal Gr → 17.64%
→ Annual Gr → 1.64%
→ India in → Very rapid growth phase
→ Population doubles in → 35-47 yrs
→ % Geriatric → 8%
→ % 0-5 yrs old → 10%
→ % urban →31.3%

II SAMPLE REGISTRATION SYSTEM [SRS]

→ Once every → 6 Month
→ Most accurate → Data collecting system b/c only dual record data in India
→ IMR, MMR, U5MR, NNMR, CBR, CDR, GR collected
→ Ministry → Home affairs

SRS 2022-23 Latest Data

CBR 19.5 per 1000 mid-year population
CDR 6.0 per 1000 mid year population
Decadal Growth Rate 13.5% per 1000 live births
IMR 28 per 1000 live births
MMR 97 per 100 000 live births

III National family Health survey [NFHS]

• Once every → 5-6 yrs by International Institute of population sciences, Mumbai Rounds completed → 5
NHFS
1. 1992-93 2. 1998-99 3. 2005-06
4. 2015-16 5. 2019-21

NHFS – 5 (2019-21)
• TFR – 2.0 STUNTING 36%
• SEX RATIO - 1020 WASTING – 19%
• IMMUNIZATION – 76% UNDER W. – 32%
• INSTIT. BIRTH – 89% ANEMIA – 57%
• CPR – 67%

IV District Level HOUSE hold Survey [DLHS]

• Once every → 5 yr
• Rounds completed → 4
DLHS 1. 1998-99 2. 2002-04
3. 2007-08 4. 2012-13

V VITAL REGISTRATION SYSTEM [VRS]

• Births → < 21 Days
• Deaths → < 21 Days
• Marriages → 30 days | 60 Days | 90 Days
• child Borne to NRI couple abroad, birth registration done with in 60 Days of arrival
• Birth Registration is responsibility of Hospital.
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FAMILY PLANNING & CONTRACEPTION

Definitions and Concepts

Eligible Couple
CURRENTLY MARRIED COUPLE, WIFE 15-49 YEARS
EC RATE – 150-180 ECs/1000 population

Target Couple
• Couple with 2-3 children
• 1 child
• NEWLY married couple

COUPLE PROTECTION RATE [CPR]

• CPR India → 66.7%
• CPR is a proportion

Effective CPR [ECPR]

Total no. of effectively protected couples x 100
ECPR =
Total no. of eligible couples

Q Total Population = 1000 Q.CPR ? Q.ECPR ?

Total EC’s = 180
FP DATA 2001 Effectivity
Condoms 29 50% → 14.5
OCPs 10 100% → 10
IUDS 10 95% → 0.95
Vasectomy 03 100% → 3
Tubectomy 08 100% → 8
60 45

CPR → 60 ×100 = 33.3% → 45 ×100 = 25%

80 180
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PSM

CONTRACEPTIVE FAILURE/CONTRACEPTIVE EFFICACY

I. Pearl Index
PI = Total no. of accidental Gestations × 1200
Total months of exposure
• Expressed per Hundred women years [HWY]
Q 100 women use ‘C’ for 2 yrs each
10 pregnancies occur.

PI → ? 10 × 1200 = 5 per HWY

24 ×100
II. Life Table Analysis
• Expressed as per single woman month of use
• Better Index

PEARL INDEX

Male Condoms 2-14 / HWY 14

Female Condoms 5-21 / HWY 21
IUDs 1-5 / HWY 2
OCPs 0.1 - 2 HWY 1
Sterilization ~ 0.1 / HWY
Vaginal Sponge 9-20 / HWY
• Vasectomy is more effective than tubectomy

Conventional contraceptives
Used exactly at the time of intercourse
1. Male Condoms
2. Spermicides
– Chemical → Non Oxynol 9
– MOA → by rupture of plasma membrane of Acrosomal cap.

INTRACEPTIVE / EMERGENCY/POST-COITAL CONTRACEPTIVES

Used after Intercourse
Combined OCPs → within 72 hrs
POPs → within 72 hrs → Recommended in
RCH
IUD → within 05 days → Most effective
→ [C/I in nulliparous]
RU - 486 [Mifepristone] → within 72 days
High dose Estrogen → x 5 days
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Family Planning & Contraception Definitions and Concepts

Combined OCPs POPs

Yuzpee & Lancee Method: 1 pill + 1 pill
4 pills + 4 pills
(12h gap)
(12h gap) < 72 hrs < 72 hrs
↓
progesterone only single pill → 0.75 mg
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Natural Methods & Barrier Methods

NATURAL METHODS
PI – 60/HWY
1. Calendar Method/ Fertile period Method/ Safe period Method/Rhythm method
2. BBT Method
3. Cervical Mucus Method
4. Symptothermic Method
5. Coitus Interruptus
6. Abstinence → PI = 0 [most effective]

Natural Methods
1. SAFE PERIOD METHOD
First day = Shortest cycle – 18
Last day = Longest cycle – 10
PI 9/HWY + Ectopic preg & Emb. anomalies
a/k/a FERTILE PERIOD M
RHYTHM M
CALENDER M
PROGRAMMED SEX (nearly ½ month abstinence)

BARRIER METHODS
MOA → Barrier b/w sperm & OVA

Male Condoms [NIRODH] Female Condoms

PI → 2-14/HWY → 5-21/HWY
HIV protection →+ → ++ (Higher)
Reusability →x →✓
Material → Latex → Polyurethane/Nitrile
Length → Shorter → Longer
No. of Rings → 01 → 02
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PSM

Fig. 1: Male, Female Condoms

DIAPHRAGM [DUTCH CAP]

Used with spermicide
• Reusable
• 4hrs ← Intercourse → 6hr (Non - conventional)
• should be educated female [Temporary spacing]
• complication → Toxic shock syndrome

Fig. 2: Diaphragm

VAGINAL SPONGE [TODAY]

Used with spermicide [Non-oxynyl 9]
• 4 hr. ← Intercourse → 4 hr. (Non - conventional)
• complication → Toxic shock syndrome
• PI → 9-20/HWY

Fig. 3: Vaginal sponge

Chemical Methods
Foams, Jellies, Spermicides
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IUDs & OCPs

IUD

1st Generation 2nd Generation 3rd Generation

Non medicators/ Inert Medicated/Bioactive Medicated/Bioactive
Lippe's Loop Copper Hormones
Grafenberg’s Ring CUT 7 Progestasert
CUT 220B LNG - IUD
CUT 380 A

CUT 380 A
• MC used IUD in India
• 380 → Surface area of Cu in mm2
• A→ Arm (Ag → CUT 380 Ag
Au → CUT 380 Au)
• * ↑ Shelf life [5yr → 10yrs]

PROGESTASERT
• Rate of Progesterone release → 65µg/Day
• Total progesterone content → 38 mg → shelf life → 1-1.5 yrs

Clinical Problems
1. MC side effect → Bleeding Management at PHC - remove
Feso4 200 mg TDS x 8 Weeks, if bleeding continues then Remove IUD
2. 2nd MC S/E → Pain
Management - Mild analgesics & wait & watch - Removal of IUD
3. Pregnancy with IUD in-situ
• Gently remove IUD
• Do medical termination of Pregnancy

IUDs [Intra Uterine Devices]

Timing Insertion

• During MENSTRUATION OR < FIRST 10 DAYS BEST

• Immediate POST PARTUM
• POST PUERPERAL – 6-8 weeks after delivery.
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PSM

COMBINED OCP’S
• Estrogen + Progesterone
• MALA N Free EE [Ethinyl Estradiol] → 30 µcg
• MALA D Rs 3/- Levonorgestrol → 150 µcg
60 mg Ferrous Fumarate
1. Maintains continuity
2. Prevents anemia
3.Withdrawal Bleeding

Fig. 1: Combined OCPs

Absolute C/I
C Cancer [Breast, Cervical]
L Liver Disease [Adenoma]
U Uterine Bleeding [Excessive & Undiagnosed]
T Thrombo -embolism
C Cardiovascular Disease
H Hyperlipidemia [congenital] Pregnancy

ORAL CONTRACEPTIVE PILLS

1. COMBINED OCPs – ADVERSE EFFECTS
• CV effects • Carcinogenesis
• Metabolic effects • Hepatocellular adenoma
• GB disease • CHOLESTATIC jaundice
• Candidiasis • Decrease Lactation
• Delayed Fertility • Depression
• Weight Gain • Migraine

ORAL CONTRACEPTIVE PILLS

1. COMBINED OCPs – BENEFICIAL EFFECTS
A. Contraceptive
B. NON- Contraceptive
• Benign Breast Disease
• Benign Ovarian Disease
• Malignant Ovarian Disease
• PID, Ectopic
• Endometrial Cancer
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IUDs & OCPs

Centchroman/Saheli /Chhaya [Re Introduced]

• Non steroidal / Hormonal OCP
• Contains ORMILOXEPHENE [SERM]
• Frequency → Once a week pill [Twice/week First 3 months]
• Central Drug Research Institute, Lucknow produced it
• PI → 1.84-2.84/HWY
• C/I in PCOD

Progesteron Only Pills

[POP’s / Lactation / Mini / Micropills / Intraceptive Pills]

Quinesterol
• Once a month pill
• No longer used

GOSSyPOL
• Male Pill
• Made from Chinese cotton Oil
• In 10% causes permanent Azoospermia.

Fig. 2: SAHELI
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Other Methods, Guidelines and Initiatives

DEPOT FORMULATIONS
Intramuscular injectable Hormones
1. DMPA → Depot medroxy Progesterone Acetate - 150 mg IM /every 3 months
- Brand name → ANTARA
2. NET-EN → Nor Ethisterone Enanthate
- 200 mg IM / every 2 month

Fig: 1 ANTARA

NORPLANT
• Subdermal Implant
• 6 Silastic capsule, 35 mg LNG each
• Surgical procedure for implantation & removal
• Shelf Life → 5 yrs

STERLIZATION GUIDELINES
Tubectomy
Female: 22 – 49 y MARRIED/ EVER MARRIED
• Minimum 1 ALIVE child (≥1 year age)
• CONSENT By SELF
• No Past H/o STERLIZATION in SELF/ SPOUSE
1. MiniLep - MBBS, MD(GYNOBS), DGO
2. LAPAROSCOPIC - MD (GYNOBS), DGO, SURGEON
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PSM

STERLIZATION GUIDELINES
VASECTOMY
MALE ≤ 60 years Age
• Minimum 1 Alive child (≥1 year age)
• No past H/o STERLIZATION in SELF/SPOUSE
1, Conventional Vasectomy
2, NSV TRAINED MBBS DOCTOR

SEMEN ANALYSIS
New WHO Guidelines "2022.
• SEMEN VOLUME : 1.4 ML
• Total Sperm Count: 39 x 106 per E
• SPERM CONCENTRATION: 16 X 106 per ML
• TOTAL MOTILITY: 42%
• PROGRESSIVE MOTILITY: 30%
• VITALITY: 54%
• SPERM MORPHOLOGY: 4%
• PH: 7.2

VASECTOMY
• Anatomical structure cut → VAS
• Minimum length of VAS cut → 1 cm
• Most useful advise post vasectomy Barrier methods x 3m
• MC Failure of Vasectomy → Surgical mis identification of VAS

NSV [No scalpel vasectomy]

• No stitch vasectomy
Small incision VAS pulled out cut, tie ends & push back small bandage
• Day care Procedure

Fig. 2: Tubectomy
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Other Methods, Guidelines and Initiatives

Fig. 3: Vasectomy

NEW INITIATIVES IN FAMILY PLANNING

1. Home Delivery Of Contraceptives
– Key health functionary incentives → ASHA
– 3 condom pack → Rs 1
– OCP cycle → Rs 1
– EC Pill → Rs 2
2. Mission Parivar Vikas [MPV]
– Accelerate use of FP methods in 146 high TFR districts
3. Ensuring Spacing at birth (ESB)
– Key health functionary → ASHA
– counselling charges → RS 500
– First child birth delayed by 2 yrs → RS 500
– 3 yr Spacing opt for sterilization → RS 1000
Cu375: 5 yrs effectivity
Post Partum IUD Insertion,
Promotion of FP services at district Hospital
4. Newer Contraceptives
– CHHAYA: Centchroman [Saheli]
– ANTARA: DMPA
5. Fixed Day Static Services Approach [Sterilization]
– DH → 21 week
– SUB DH [SDH] → Weekly
– CHC/BLOCK PHC → Fortnightly
– PHC/24X7 PHC → Monthly
6. Pregnancy Testing Kits
– NISCHAY
– Available at ASHA, Sub-centers
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PREVENTIVE OBSTETRICS AND PEDIATRICS

Preventive Obstetrics

PREVENTIVE OBSTETRICS
Obstetric Care In RCh
MCH RTI/STT
NFPP CSSM RCH

1951 1992 1997

(NHM - 2013)

NFPP → National Family Planning Programme

MCH → Maternal & Child heath
CCSM → Child Survival Safe Motherhood
RTI → Reproductive Tract Infections
STI → Sexually Transmitted Infections
NHM → National Health Mission
RCH → Reproductive & Child Heath programme [part of NHM-2013]

Obstetric Care (Earlier)

Obstetric and Newborn care

Essential ONC Emergency ONC

Level I BEMONC (Basic) CEMONC (Comprehensive)

PHCs Level II Level III
24 × 7 PHCs, CHCs DH, FRU’s

Essential ONC BEmONC

Registration Manual Removal of Placenta
AN care Oxytocin
Safe Delivery Antibiotics
PN care Anticonvulsants
New Born care Assisted Delivery
Vacuum Aspiration
NB Resuscitation
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PSM

CEmONC (BEmONC plus)

1 Surgery
2.Blood Transfusion

AN VISITS
• Recommended AN Visits → 13 –14
→ Monthly 0 – 7 month → 7
→ Twice a month 8th month → 2
Once/week 9th Month onwards → 4–5
[13-14 TOTAL]

• Minimum AN Visits → 4 [WHO 8]

1 → Registration
2 → 14 – 26 Wks POG
3 → 28 –34 wks POG
4 → 36 W – Delivery
• Minimum PN visits → 3–4
→ 3 in Institutional delivery [Day 3, 7, 42]
→ 4 in home delivery [Day 1, 3, 7, 42]
MPW [F]/ANM takes the responsibility of PN visits
ASHA workers Post natal visits separately → 6 – 7 [HBNC]
• 6 in Institutional delivery → Day 3 7 14 21 28 42
• 7 In home delivery → Day 1 3 7 14 21 28 42

MCh INDICATORS
IMR [Infant mortality Rate] → Infant < 1yr
MMR [Maternal Mortality Rate] → Maternal Death
Any time in pregnancy, labour/delivery or <in 42 days of delivery
U5MR [under 5 mortality Rate] → U5 Death → 0 – 5 yrs
NNMR [Neonatal Mortality Rate] → NN Death → 0 – 28 Days
PNMR [Perinatal mortality Rate] → PN Period → 28 wks POG till 7 D Post delivery

SBR [Still Birth rate] → Still Birth → POG > 28 wks, BW > 1000 gms, BL > 35 cm

MCC India
Infant Death
IMR → × 1000 [28] LBW & Prematurity
Live Birth
Maternal Death
MMR → × 100 000 [97] PPH
Live Birth
Under 5 Death
USMR → × 1000 [32] LBW & Prematurity
Live Birth
Neonatal Death
NNMR → × 1000 [20] LBW & Prematurity
Live Birth
Perinatal Death
PNMR → × 1000 [18] LBW & Prematurity
Live Birth
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Preventive Obstetrics

Still birth
SBR → × 1000 [21] Maternal infections Abrupton Placenta
Live Birth

AT RISK APPROACh

1. At Risk Mothers
• Elderly Primi (≥ 40 Y)
• Short Stature Primi (Ht. < 140 Cms)
• Malpresentation
• Threatened Abortion
• APH, PreE, Ecclampsia
• Twins, Hydramnios
• H/O IUD, Still Birth, MRP
• Elderly Grand Multipara (≥ 5 B. O.)
• Prolonged Preg. (≥ 14 Days of EDD)
• H/O CS Or Inst. Delivery
• DM, HTN

2. At Risk Infant
• Lbw (< 2.5 Kg)
• Twins
• Birth Order ≥ 5
• Artificial Feding
• W. < 70% of Expected (2 Or 3 degree Malnurition)
• Failure To Thrive (≥ 3 Months)
• PEM, Diarrhoea
• Working Mother
• Single Parent

3. Danger Signals During Labor

• Sluggish/No Pain After Memb. Rupture
• No Progress Of Labor After Memb. Rupture
• Hand/Cord Prolapse
• MSL
• Slowirregular/ Fast Fetal Hs
• Excessive Show
• Collapse
• PPH, Collapse
• Placenta Not Seprated > ½ Hr.
• Temp. > 38°C

IFA TABLETS [Anemia Mukt Bharat]

Adult tablet Kids Syrup
Iron 60 mg 20 mg
Folic Acid 500 mg 100 mg
1 tab/D x 180 Days 1 Bi weekly
[4-5-6 m POG] [6-59 moths of age]
&
[Lactation/3m]
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PSM

TT in Pregnancy [Now REPLACED BY Td]

Primi → 2 doses [1month apart] → ASAP in Pregnancy
[ No C/I in 1st/Trim]
2 doses → Total duration of Protection ~ 5 yrs
Next Pregnancy occur with in 3 yrs or only 1 Booster Dose [ASAP]
– 1 Dose in current pregnancy & Next pregnancy after 3 yrs
– 2 Doses of Td ASAP [1 month apart]

OBSTETRIC CARE IN RCh

Safe Delivery
• CLEAN HANDS
• CLEAN SURFACE
• CORD CUT [clean blade] 5 CLEANS
• CORD TIE 7 CLEANS
• CORD STUMP [Not apply anything to stump]
• CLEAN WATER
• CLEAN TOWEL

LAQShYA
[Labour Room Quality Improvement Initiative]
• Improving the quality of maternity and labor room
Role: to reduce the adverse outcome related to child birth

Fig. 1: LAQSHYA

PMSMA
[Pradhan Mantri Surakshit Matritva Abhiyan]
• High quality , comprehensive anc given free on 9th date of every month at
– All government institutions
– Empaneled private health facilities
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Preventive Obstetrics

Fig. 2: PMSMA

SUMAN – 2019
[Surakshit Matritva Aashwasan]
GOAL – ZERO MATERNAL AND NB DEATHS
Target beneficiaries:
• Pregnant mothers
• Mothers after delivery till 6 monrths
• Newborns

Fig. 3: SUMAN
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Preventive Pediatrics

Birth Weight
• Average Birth Weight →2.8 Kg
• LBW in India →2.5 Kg
• If pre term Delivery, LBW →2.5 g
[LBW doesn't depend on Period of Gestation]
• Minimum samp Size required to estimate prevalence of LBW →500

Fig. 1: Salter scale, Infantometer

WHO classification of LBW

LBW < 2.5 Kg
• MLBW < 2.0 Kg
VLBW < 1.5 Kg
ELBW < 1 Kg

PRE TERM < 37 WKS

TERM 37-42 WKS LBW SFD/SGA <10th percentile weight
[Small for date] for Gestational age
POST TERM > 42 WKS LBW MCC → IUGR
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• BW measured by → SALTER’S SCALE [spring Balance]

• BW Double by → 5m
• Triples by → 2 yrs

Birth Length
• Average BL India → 50 cms
• Ht at the end of Infancy → 75 cms
• Ht doubles by → 4 yrs
• Field instrument → Infantometer

Breast Feeding
• Exclusive Breast Feeding till → 0-6 months
• Breast feeding till → 0-2 yrs
• Vaccines [OPV, Rotaviral vaccines Medications ORS → Permitted in Exclusive breast feeding
Vit B supplementation
• Energy content → 65 Kcal/100ml
• Protein content → 0.9 to 1.1gm/100ml
• Most abundant type of Ig → Ig A > Ig D, Ig G, 1g M , Ig E
Most abundant Ig in colostrum/beestings
• EFA exclusive to Breastmilk → DHA helps in
Brain development [myelination]
• AA in Breast milk → Taurine [useful In Brain development]
• Vitamin most deficient in milk → Vitamin c
• Vitamin Most def. in Breastmilk → Vitamin D

Breast Feeding Initiation Guidelines

• After a normal vaginal Delivery → ASAP/< 1hr
• After CS → ASAP/< 4hr

Higher Quantities in

HUMAN MILK COWS MILK

LACTOSE Energy
Iron Proteins
Water Fats
Ca2+: P Ratio Calcium, Phosphorus
Vit A, C Vit B,D
Cu, Co, Se Na+, k+
cysteine, Taurine Methionine
Linoleic Acid
PUFA
Casein : Whey [40:60] Casein: Whey [80:20]
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Preventive Pediatrics

GOOd AttACHMeNt
1. BaBy’s chin touches Breast
2. BABy"S MOUTH WIDE OPEN
3. LOWER LIPTURNED OUTWARDS
4. more areola visiBle aBove BaBy’s mouth

PReVeNtIVe PAedIAtRICS [NN HYPOtHeRMIA]

Kangaroo Mother Care
• KANGAROO POSITION (SKIN TO SKIN)
• KANGAROO FEEDING POLICy (ADEQUATE NUTRITION)
• EARLy DISCHARGE AND AMBULATORy CARE
• SUPPORT TO MOTHER AND CHILD CARE

GROWtH & deVeLOPMeNt & NUtRItIONAL StAtUS

Best Indicators In Children
1. Growth → Weight [Weight for Age]
Development → Weight [Weight for Age]
Nutritional status → Weight [Weight for Age] best
→ Mac [mid Arm circumference] Second best

Fig. 2: SHAKIR'S tAPe

MId ARM CIRCUMFeReNCe

• Field instrument → SHAKIR's TAPE
• Normal → 13.5 cm[Green] → Home Mx
• Mild-mod PEM → 12.5-13.5 cm (yellow) → PHC Mx
• PEM Severe → 12.5 [Red] → Referral
• Age group → 6 m - 5 yr
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PSM

Fig. 3: SHAKIR'S TAPE

PeM StAtUS INdICAtORS

1. Low wt. for Age → UNDER WEIGHT → Acute on chronic PEM
2. Low Wt. for Height → Wasting → Acute PEM
3. Low Ht for Age → STUNTING → Chronic PEM

GROWtH CHARt
• Passport to child growth
• Given by DAVID MORLEy
• 55 types +nt

Fig. 4: WHO growth chart

1. WHO GROWTH CHART has 2 Reference Curves:
– URC: Upper reference curve → 50th percentile for Boys
– LRC: Lower reference curve → 3rd percentile for Girls (= 80 % of URC) lies - 2SD beloe URC Based
on NCHS [National center for Health Statistics]
2. ICDS Growth Chart [Integrated Child Development Services]:
Used @ ANGANWADI (3 Reference Curve)
– Standard line → 50th percentile for Boys (URC WHO)
– -2 SD line → 3rd percentile for girls (LRC WHO)
– -3 SD line
– Based on MGRS [Multicentric Growth Reference study] Standards = WHO child Growth standards
2006
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Preventive Pediatrics

Fig. 5:ICDS growth chart

Under Fives’ Clinic

5 Components:
• Preventive Care
• Growth Monitoring
• Care In Illness
• Family Planning
• Health Education

Fig. 6: under Fives’ clinic

CHILd PLACeMeNt
5 AREAS
1. Orohanages: foe children who have no homes, no parent or parent cannot take care of child
2. Foster homes: facilities which have special caregiving facilities for rearing childrenabove than their
natural family
3. Adoption
4. Bostals – meant for:
– Boys >16 years
– Lie b/w school & prison
– Usually for 3 years- training and reformation
5. Remand home: under care of a doctor, psychiatrist or other healthcare personal
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SCHOOL HeALtH
• First Recommended By Bhore Committe [1943]
• School Health Programme by RENUKA ROy Committee [1960]

Healthful School envirement

1. Class Room <40 Students
2. Per capita space > 10 sq. Feet
3. Door & Window area > 25% of Floor area
4. Desk -minus type
5. Natural light from left side

Fig. 7: Types of desks

6. 1 urinal / 60
7. 1 sanitary Latrine / 100
8. Recommended Frequency of School Health Examination once/6 month

School Vision Programme

• Screening done by class teacher
• 1 Teacher per 150 student
• Class 5 to 8 (10 to 14 years age)
• Visual Acuity cut off for Referral → 6/9.
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Preventive Geriatrics

PREVENTIVE GERIATRICS
• Geriatric Age → 60 yrs
• Geriatric population → 8%
• MC health disorder → cataract
• MCC of Death in > 70y → Cardio vascular Diseases

NPOP 1999
[National Policy For Older Personr]

UNDER ‘MOSJE’
Key Ares of Focus
• Financial Security
• Shelter
• Education
• Welfare
Fig 1: Geriatric
• Proection of Life and Property
Travel, Entertainment & Legal

NPHCE 2011
[National Prog. For Health Care of Elderly]

Under 3 Levels:

Level Done under

Primary Subcentre, HWCs, PHC
Secondary CHC, DH
Tertiary Regional getiatric centre (Has 2 apex bodies)

Has 3 Components
1. NHM: Primary and Secondary Levels
2. TERTIARY COMPONENT – VIA RVJSY 2016-17 [Rashtriya Varishth
Jan Swasthya Yojana]
3. RESEARCH – LASI PROJECT [Longitudinal Ageing Study in India]

Fig 2: NPHCE
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NUTRITION
Definitions and Concepts

NUTRITION & HEALTH

Nutrition: Science that studies interaction of nutrients in relation to the maintenance, growth repair, health &
disease in body.

Macro Nutrients grams/day Micro Nutrients mg/day Trace Nutrients → mcg/day

1. Carbohydrates a. Iron
2. Fats b. Iodine
3. Proteins c. Zinc
d. Calcium
e. Vitamin A

PROXIMATE PRINCIPLES ≠ MACRO NUTRIENTS

Fats Proteins Carbs

Energy Fats [9 K.cal/gm] Proteins [4.2 cal/gm] >carbs [4.1 K. Kcal/gm]
Balanced diet 15-30 % 10-15 % 50-70%

Consumption Unit

Adult Male Adult Female

Sedentary 1.0 0.8
Moderate 1.2 0.9
Heavy 1.6 1.2
Adolescents 12-21Years 1.0
Child 1-3 Y …0.4
3-5…..0.5
5-7….0.6
7-9…0.7
9-12…0.8
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RDA & Rich Sources

PROTEINS, FATS, RICH SOURCES

Proteins

Quantity Quality

1. Protein Energy Ratio Best indicator - ↓ ing order

1. Digestible Indispensable AA score [DIAAS] (Best Overall)

2. Protein Digestibility corrected AA score [PDCAAS]

3. Net Protein Utilization

4. Amino Acid score

5. Biological value

6. Protein efficiency ratio

NPU [Net Protein Utilization]

BV: Biological value
DC: Digestibility Co-efficient
NPU → =BV/DC x 100
•• →Highest NPU found in Egg → 96
Milk → 81
Meat → 79
• Highest quality → EGG → REFERENCE PROTEIN
Highest quantity → Soyabean [43.2% proteins

EGG
6g Proteins
6g Fats
1.5mg Iron [Fe2+]
30 mg Calcium
250mg Cholesterol (richest source)
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PSM

70 K.cal Energy
• Highest NPU is due to it contains all essential Amino Acids in balanced proportions

SOYABEAN [Among pulses]

• Highest Proteins [43%]
NPU
FAT
Energy [432 kcal/100g]
Iron
Vit B1,B2

Fig. 1: Soyabean

ESSENTIAL AA [EAA]
• 10 [8 + 2]
• P Phenyl Alanine
V Valine
T Tryptophan
T Threonine
I Isoleueine
M Methionine
H Histidine
A Arginine
L Leucine
L Lysine

LIMITING AMINO ACIDS

• Deficient in a food item
• 1. Maize → Tryptophan & Lysine
• 2. Cereals → Threonine & Lysine
• 3. Pulses → Methionine & cysteine
• Supplementary Action of proteins = Two different food items must be eaten together
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RDA & Rich Sources

FATS
Essential Fatty Acids [EFA]
• Linoleic Acid →•Most essential
Linolenic Acid
Arachidonic Acid
Eichosa Pentatonic Acid
Docosa Hexanoic Acid [DHA]

RICHEST SOURCES
Order

Fig. 2: (a) Sun Flower (b) Safflower

1 EFA
Safflower oil (Richest source)
Sunflower Oil
Corn Oil
Soyabean Oil
Olive Oil
Groundnut Oil
Coconut Oil
2. Linoleic Acid Safflower Oil
3. Arachidonic Acid Safflower Oil
4. PUFA Safflower Oil
5. MUFA → Olive Oil
6. SFA → Coconut oil
7. Linolenic Acid → Flax seed Oil > soyabean oil
8. EPA → Fish Oils
9. Iron → Dried Pumpkin seeds (Richest)
Pistachio Nuts
Cashew nuts
10. Vitamin A
Overall → Halibut Fish liver oil, other Fish liver oils.
Fruits → Ripe Mango
Vegetables → Carrots
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PSM

Fig. 3: Halibut Fish

11. Vit D
Overall → Fish liver oil [Halibut]
Fruits → x
Vegetables → x

Vit D

No plant source

Vit B12

Strict vegetarians develops deficiency of B12

12. Vit C

• Amla [Indian Gooseberry] (Richest)

• Guava [Non citrus]
• Cabbage [Vegetables]
• Other citrus fruits
13. Golden Rice
– Genetically modified crop [GMC]
– Rich in B-Carotene

Fig. 4: (a) Polished Rice (b) Golden Rice

POOR SOURCES
Egg Carbohydrates & Vit C
Milk Iron & Vit C
Meat Calcium
Fish Carbohydrates & Iodine
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RDA & Rich Sources

NUTRITION GUIDELINES 2021-22

Fig. 5: Nutrition Guidelines 2021-22

These guidelines are devised by
1. Indian Council of Medical Research, (ICMR), New Delhi
2. National Institute of Nutrition (NIN), Hyderabad
3. Department of Health Research, New Delhi
4. Ministry of Health & Family Welfare, New Delhi
Reference Body Weight: (BMI Normal 18.5-22.9)

Indian reference Man Women

Newer 19-39y 19-39y
(95 Percentile Weight / Height)
th
65Kg 55Kg
Energy Requirement Guidelines:

Adult Man Adult Woman

Sedentary 2110 1660
Moderate 2710 2130 Heavy
Heavy 3470 2720

Infant 0-6m 550 Kcal/day

6-12m 670 Kcal/day
Children 1-3y 1000 Kcal / day
4-6y 1400 Kcal / day
7-9y 1700 Kcal / day
Carbohydrates: Grams/day PROTEINS (grams/day)
Man 130 g/day 54
Woman 130 g/day 45.7
Pregnancy 175 g/day II+9.5 + 22 III
Location 0-6m 200 g/day + 16.9
6-12m 200 g/day + 13.2
Infants 0-6m 55 g/day 8.1
6-12m 95 g/day 10.5
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Iron
Absorption for adjustment of Dietary Iron
Men, Children 3%
Women 8%

Dietary FiBres
Non-Starch Polysaccharide
Insoluble Fibres Soluble Fibres
Cellulose Pectins
Hemi-Cellulose Gums
Lignin Mucilages

Density of Ascorbic Acid in Daily Diet

20mg / 1000 kcal

Recommended Dietary allowance.

Iron Mg / day Folic Acid Mcg /d
Man 19 300
Woman 29 220
Pregnancy 40 570
Lactation 23 330
Calcium Mg / day Phosphorous
Man 1000
Woman 1000 1:1
Pregnancy 1000
Lactation 1200

Iodine: Mcg / day Zinc mg/d

Man 150 17
Woman 150 13.2
Pregnancy 250
Lactation 280

Other Nutrients:
VitaMiN D (iU/day)
Phosphorus 100 mg / day
Man - 600
Sodium 2000 mg / day Woman - 600
Potassium 3500 mg / day Pregnancy - 600
Copper 2 mg / day Lactation - 600

Manganese 4 mg / day
Chromium 50 mcg / day
Selenium 40 mcg / day
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RDA & Rich Sources

Vitamin A “Mcg / day”

Man 1000
Woman 840
Pregnancy 900
Lactation 950

Other Vitamins Man Woman

Thiamine 1.4-2.3 Mg / day 1.4-2.3 mg / day
Riboflavin 2-3 mg / day 2-3 mg / day
Niacin 14-23 mg / day 11-18 mg / day

B6 2-3 mg / day 2-3 mg / day

B12 2.5 mg / day 2.5 mcg / day

Vitamin C 80 mg / day 65 mg / day
Vitamin E 7.5-10mg / day 7.5mg-10mg / day
Tocopherol Tocopherol
Vitamin K 55 mcg / day 55 mcg / day
Vitamin D 600 IU / day 600 IU / day
Same in pregnancy
& Lactation

Water:

Man Woman
32-58 ml / kg body mass 27-52 ml / kg body mass

Pregnancy 2.1 -3.2 L / day

Antioxidants
B carotene, C, Polyphenols, flavonoids, E

Fruits / vegetable 400g / day.

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Nutritional Deficiencies

VITAMINS & DEFICIENCIES

Vitamin A Deficiency – Xerophthalmia
• Vit A deficiency leads to Xerophthalmia [WHO]

Fig. 1: Bitot spots

Primary Secondary
X1A → Conjunctival Xerosis XN → Night blindness/ Nyctalopia
X1B → Bitot spots XF → Fundus
X2 → Corneal Xerosis XS → Scarring
X3A → Corneal Ulceration
X3B → Keratomalacia

First sign Conjunctival Xerosis / Dry Eye

First symptom Night Blindness
First manifestation Night Blindness
First Specific Manifestation → Bitot’s spots
• Xerophthalmia as a public health problem
– If prevalence of night blindness > 1%
– If prevalence of Bitot’s Sports > 0.5 %
• Rx of Xerophthalmia
Day ≥ 1 year < 1 year
0 2 lakh IU 1 lakh IU
1 2 lakh IU 1 lakh IU Oral Dose

>14 2 lakh IU 1lakh IU

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PSM

• 1 Lakh IU = 30 mg
1
• IM dose = the oral dose
2

VITAMIN B1 [THIAMINE]
Deficiency leads to
1. Beri Beri → Seen in Polished rice eaters
2. Wernicke’s Korsak off Psychosis → Seen in Alcoholics

VITAMIN B2 [RIBOFLAVIN]

Fig. 2: VITAMIN B3 [NIACIN]

• Deficiency Pellagra
– seen in Maize eating Population
Tryptophan B3
60 mg – 1 mg
Leucine excess
[Pellagrogenic AA]
– 3D’s Diarrhoea, Dermatitis, Dementia
– 4th D – Death
– 5th D – Delirium
– 6th D – Depression

Vitamin B5 [PANTOTHENIC ACID]

• Deficiency leads to Burning Feet/Sole Syndrome

Vitamin B6 [PYRIDOXINE]
• Deficiency → Microcytic anemia
Peripheral neuritis
• Seen in Isoniazid takers [of NTEP] → supplement with B6

Vitamin B9 [FOLIC ACID]

• Deficiency leads to
– Megaloblastic Anemia
– Neural tube defects
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Nutritional Deficiencies

NUTRITIONAL DEFICIENCIES – VITAMIN K

K1: PHYLLOQUINONE
K2: MENAQUINONE
K3: MENADIONE
HEMORRHAGIC DISEASE OF NB

VKDB
[1MG PHYTADIONE(K1) IM AT BIRTH]

Vitamin B12 [CYANOCOBALAMIN]

• Deficiency leads to
– Megaloblastic anemia
– Pernicious anemia
– Peripheral neuritis
– SCDSC [Sub acute combined Degeneration of Spinal cord]

Vitamin C [ASCORBIC ACID]

• Deficiency leads to SCURVY – C/F
– delayed wound healing
– Gum bleeding
– Fractures (BUT NO STERILITY)

Vitamin D (Ergo calciferol [D2], cholecalciferol [D3])

• Deficiency → RICKETS [children]
Osteomalacia
[Adults]
Osteoporosis

NUTRITIONAL DEFICIENCIES
• Vit E deficiency → Progressive ext. opthalmoplegia
• B2 deficiency [Ocular] →↑ Circumcorneal congestion
• Zn deficiency → Acro Dermatitis enteropathica
• Vit B6 deficiency → Seizures [Infants]
• Chromium deficiency → Glucose Intolerance
• Zn deficiency → Impaired Glucose Metabolism
• EFA deficiency → PHRYNODERMA [Toad like skin]
• Selenium deficiency → Endemic cardiomyopathy of India [KESHAN’S DISEASE]

FLUORINE
(a) MC source Drinking water
(b) Optimum level of intake 0.5 – 0.8 ppm
(c) Acceptable level of intake 1 – 2 ppm
(d) Dental Fluorosis > 1.5 ppm
(e)Skeletal Fluorosis 3 –6 ppm
(f) Crippling Fluorosis > 10 ppm
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PSM

Fluorosis d/t excess of fluorine

DEFLUORIDATION OF WATER
1. Nalgonda Technique
– Developed by NEERI NAGPUR [National Environmental Eng. Research InS.]
– Sequence [Mnemonic – LAB]
L. Lime
A. Alum
B. Bleaching Powder
2. Phosphates
First fluorine changes in body → Upper central Incisors & 1st Molar.
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Food Standards, Adulteration

FOOD STANDARDS IN INDIA

Fig. 1: NIN, Hyderadad

1. CODEX ALIMENTARIUS [International]
2. PFA standards [Prevention of Food Adulteration 1954 Act]
3. BIS standards [ Bureau of Indian Standards]
4. Ag Mark Standards
5. FSSA standards [Food Standards & Safety Authority]
– Indian food standards mainly based on Codex Alimentarius
– Minimum prescribed food standards in India → FSSA standards

MILK BORNe DISeASeS

INFeCTIONS OF ANIMALS
Primary Importance Secondary Importance
Tb Anthrax
Staphy. Food P. Cowpox
Streptococcal I. Food and Mouth Diseas
Salmonellosis Leptospirosis
Q Fever Tick Enc.
Brucellosis
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PSM

INFeCTION PRIMARY TO MAN

DIARRHOeAL NON-DIARRHOeAL
E. Coli TB
Cholera Diphtheria
Shigella Strep
Typhoid, Para T Enteroviral
Hepatitis

PASTeURISATION OF MILK
Methods
• Holder/Vat M – 63-66°C × 30 Min.
• HTST/Flash - 72° × 15 Sec. (MC)
• HHST/Batch – 68°C × 30 Min.
• UHT - 125°C Few Seconds

SUFFICIeNCY CHeCK OF PASTeURISATION

• Phosphatase Test (MC)
• Standard Platelet Count
• Coliform Method

TeST OF MILK CONTAMINATION

• Methylene Blue Reduction Method

FOOD ADULTRATION
• → Deliberate addition, deletion or substitution OR Mismatch b/w actual contents & those mentioned
on food Pockets

Food Adulteration Diseases

Disease Toxin Adulterant Food
Lathyrism BOAA[β oxalyl Khesari Dal Arhar Dal
Amino Alanine [L.sativus]
Epidemic Dropsy Sanguinarine Argemone Oil Mustard Oil
Endemic Ascietis Alkaloids [pyrollizidine] Crotolaria Food dishes
Ergotism Ergot toxin Claviceps Cereals
Aflatoxosis Aflatoxin Aspergillus Ground nuts
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Food Standards, Adulteration

FOOD ADULTRATION
Toxin Adultrant Food
Lathyrism: BOAA Lathyrus Sativa Arhar Dal
• Removal of Toxin
– Steeping
– Parboiling
• Ban the Crop
• Vit. C Prophylaxis
• H. Education
• Gen. Engg. Methods

Fig. 2: Lathyrism

ADULTeRANTS
• Black pepper → Dried Papaya seeds
• Red pepper → Brick powder
• Turmeric → Lead chromate
• Coriander Powder → cow dung

TYPeS OF VeGeTARIANS
Vegan No Animal Products
Semi-Vegetarian Dairy, Eggs, Chicken, Fish
Pollo-Vegetarian Dairy, Eggs, Poultry
Pesco-Vegetarian Dairy, Eggs, Fish
Lacto- Vegetarians Dairy
Ovo- Vegetarians Eggs
Lacto-Ovo Vegetarians Dairy, Eggs
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PSM

NUTRITIONAL ASSeSSMeNT

1. Diaetry Intake Dietary Cycle Diet Survey

2. Nutritional Intake
Clinical Exam
Anthropometry Cooked Food
Biochem & Lab Exam
Functional Assessment Oral Ques.
Assess Dietary Intake
Vital Stat
Ecological studies

Dietary cycle is raw food weighment in 7 days

NNM Poshan Abhiyan

MALNUTR. FREE By 2022 (REDUCE PREVALENCE By)
• Stunting 2% Per year
• Under Weight 2% per year
• Low birth W 2% per year
• Anemia 3% per year
Stunting 38.4% to 25% (mission 25)

GLYCeMIC INDeX:
Definition: area under the 2-hour glucose response curve (AUC)
Low glycemic index foods: less readily digestible and lower absorption of sugar
GLUCOSE is taken as STANDARD [GI = 100]
Classification of glycemic index (GI):

Classification Gi range examples

Low GI ≤ 55 Most fruits and vegetables (except potato/water-melon/sweet

potato), whole grains, beans, pasta, lentils
Medium GI 56 - 69 Sucrose, basmati, rice, brown rice

High GI ≥ 70 Corn flakes, baked potato, white breads, candy bar, syrupy food,
jasmine rice
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ENVIRONMENT
Water

Safe & Wholesome Water

• Free from color/odour
• Free from chemicals
• Free from Biological agents
• Usable for domestic purpose

Disinfection of Water
1. Boiling (Best) • Cyclops
2. Chlorine (2nd best); • Polio virus
• Hepatitis A
Chlorine has No effect on
• Helminthic cysts
3. UV rays • Helminthic ova
4. Ozone gas • Bacterial spores

• Chlorine → Only Method Having Residual Action

Chlorination
• Cl2 Acts Best If Ph 7
• % available Cl2 in Bleaching Powder → 33%
• 2.5 gms of bleaching powder is sufficient to disinfect 1000L of water

MOA
CHLORINE + IMPURITIES

DESTRUCTION Add some additional Cl2 [free residual Cl2]

• Main disinfecting action of chlorine in water is due to HYPOCHLOROUS ACID [HOCL] [90% of disinfection]
+ Hypochlorite ions [10% of disinfection]

Free/Residual Chlorine Levels Recommende

1. In drinking water → ≥ 0.5 mg/L with contact period of 1 hr.
2. in drinking water to kill cyclops → ≥ 2.0 mg/L with contact period of 1 hr.
3. Swimming Pools of India → ≥ 1.0 mg/L [PPM] with contact period of 1 hr.
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• Free chlorine level can be estimated by → Chloroscope → Tests

Fig. 1: Chloroscope
OT Test (Ortho Toluidine Test) OTA (Ortho Toluidine Arsenic Test)
01. Free Chlorine [Directly] 01. Free Chlorine [Directly]
02. Total Chlorine [Directly] 02. Combined Chlorine [Directly]
03. Combined chlorine [Indirectly] 03. Total Chlorine[Indirectly]
• OTA is better than OT Test
– gives free & combined levels separately
– not affected by inorganic impurities in water.

Chlorine Demand
• Estimated By Horrock’s Apparatus
• 6 While Cups & 1 Black Cup
• Indicator → Starch Iodide

Fig. 2: Horrock' s apparatus

Q. Grams of bleaching powder required to disinfect 2250 L water, where 3rd cup is the First cup to show
Color change in Horrock’s apparatus
→n=3
[3x2] gm required for 455L water

2250 L require = x 6 = 30 gms of B. Powder

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Environment Water

HARDNESS OF WATER
• Soap destroying power of water Hardness
TEMPORARY PERMANENT
• D/t Ca2+/Mg2+ salts of Bicarbonates D/t Ca2+/Mg2+ salts of Sulphates/Chlorides Nitrates
• Softening of drinking water is done if hardness is > 150 mg/L [> 3 mEq/L]

Temporary Hardness Permanent Hardness

• Boiling • NaCO3
Removal of Hardness of water • Lime • Base Exchange
• NaCO3
• permutit

Rapid Sand Filters Slow Sand Filters

MECHANICAL BIOLOGICAL
SPACE LESS SPACE MORE SPACE
FILTRATION RATE 200 mgad 2-3 mgad
SIZE OF SAND 0.4-0.7 mm 0.2-0.3 mm
WASHING Backwashing Scraping
FREQUENT WASHING YES NO
OPERATIONS Highly skilled Low skills
LOSS OF HEAD ALLOWED 6-8 feet 4 feet
REMOVAL OF BACKTERIA 98-99% 99.9-99.99%

Public Health Classification of Water Borne Diseases

1. WATER BORNE DISEASE
Feco – oral
• Typhoid
• Salmonella
• Cholera
• E. coli
• Polio
• Hepatitis A
• Rota Virus
2. Water Washed Diseases
• Inadequate use of water
• Scabies
3. Water Based Diseases
• Some Organism Based in water
• Guine worm Disease
4. Water Breeding Diseases
• Insect related
• Malaria, Dengue
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Bacteriological Indicators of Water Quality in India

1. Coliforms [E. coli] → Best overall
2. Fecal Streptococci → Indicates recent contamination of drinking water
3. Clostridium Perfirenges → Indicates remote contamination of during water

Screening Tests of Coliforms in Drinking Water

1. Presumptive Coliform Test (Screening test)
[MPN multiple Tube method] MPN - most probable number
- Uses Mc CRADY TABLES
2. Diagnostic Tests → EIJKMANN TEST

Guideline Aspects of Drinking Water Quality in India

→ Colour → < 15 TCU [< 5 HAZEN]
→ Turbidity → < 1 NTU
→ Hardness → < 100-300 mg/L
→ PH → 6.5 - 8.5
→ TDS → < 500 mg/L
→ Fluorides → < 1 ppm
→ Nitrates → < 45 mg/d
→ Nitrites → < 3 mg/d
→ Radio Activity → α < 0.5 Bcq/L
→ β<1.0 Bcq/L
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Air

Fig. 1: Sling psychrometer, Kata thermometer

INSTRUMENT USED TO ASSESS

Kata Thermometer Low Air Velocity
Hygrometer Air Humidity
Psychrometer Air Humidity
Anemometer Air Velocity
Wind Vane Air Direction
ANEROID Barometer AIR PRESSURE
MERCURY Barometer AIR PRESSURE
GLOBE Thermometer MEAN RADIANT TEMPERATURE
SIX’S Minimum & Maximum Thermometer AIR TEMPERATURE
SILVERED Thermometer AIR TEMPERATURE

HOUSING STANDARDS & VENTILATION STANDARDS

• Per Capita Air Requirement → 300-3000 cu. ft/Hour [~1000 - 1200 cu Ft]
• Recommended no. of air changes/hr. in
– Living Room → 2-3
– Clinic → 4-6
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Types of Ventilation
1. Exhaust ventilation → Pushes older air out of the room
2. Plenum ventilation → Pushes Fresh air in the room
3. Balanced ventilation → Exhaust + Plenum ventilation
4. Air conditioning

Air Pollution

Indicators CO2 CO
SO2 NO2
Air Pollution Index
Soiling Index
Coefficient of Haze
SPM [Suspended Particulate matter]

• Overall best Air Pollution Indicator

• Overall best chemical Indicator of AP SO2
• Best biological Indicator of Air Pollution → LICHENS
• Air Pollution Monitoring → CPCB [Central Pollution Control Board]

AIR QUALITY MONITORING

CPCB NAQI
[NATIONAL AIR QUALITY INDEX]
8 PARAMETERS:
SO2 LEAD
NO2 OZONE
CO PM 2.5
NH3 PM10

Fig. 2: NAQI CBCP

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Air

GLOBAL WARMING / GREEN HOUSE EFFECT

Major contributor → 1. Water vapor > 2. CO2

Kyoto Protocol
• Signed by 187 countries in 16 feb, 2005
• Includes CO2, N2O, CFC, CH4, SF6, PFC

1990 Base Line

↓ 5% emission 2008–12

↓ 18% emission 2013–2020

Fig. 3: Kyoto protocol

• Minimum Illumination level for satisfactory vision → 15-20 Foot candles

• Day Light factor [DLF]
– Living Room → ≥ 8%
– Kichen → ≥ 10%

P4SR
→ Predictable 4 hr sweat rate
→ For comfort Level → 1-3 liters
→ Max permissible/max P4SR → < 4.5 liter
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Light, Sound, Housing, Radiation, Waste Disposal

LIGHT MEASUREMENT UNITS:

Luminous Intensity
Candela
Brightness of Point Source
Lumen Luminous Flux
Flow of Light
Lux Illumination, Illuminance
Amount of Light Reaching Surface
Lambert Brightness, Luminance
Amount Oof Light Emitted By Surface

SOUND
→ Tolerable Sound level to human ear → < 90dB
→ Auditory Fatigue Starts → > 90dB
→ Permanent Hearing loss → > 100dB
→ Direct Tympanic membrane Rupture → 150–160 dB
→ Hospital ward [Permissible level] → 20–35 dB
→ Normal conversation → 60–70 dB

HOUSING
Housing Standards – Urban
• SITE, SETBACK 2/3 FLOOR PUCCA 2-3 PLINTH
• WALL > 9 INCH
• ROOF > 10FEET
• ROOMS
• FLOOR AREA 50-100 ft²/person
• DLF ≥1%
• CUBIC SPACE > 500ft³
• DOORS + WINDOWS > 2/5 of floor area
• KITCHEN, PRIVY, GARBAGE/REFUSE, WATER SUPPLY
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HOUSING HOUSING STANDARDS ~ RURAL

• Living Rooms >2
• VERANDAH - AMPLE
• Built up Area > 1/3
• kitchen - Separate
• Sanitation Latrine - sanitary
• WINDOWS 10% of FLOOR area
• SANITARY WELL 1/4 OF MILE
• CATTLE SHED 25 ft Away

Overcrowding Criteria
• No. of persons/Room → >2
• Floor space/person → < 70–90 Ft2
• Sex separation> 9 Yrs age → Absent

Radiation
• Radiation exposure in Chernobyl tragedy CS, I2, Sr
• Thickness of Lead apron to prevent exposure ≥0.5mm
• State receives highest Solar Radiation Rajasthan
• Total natural radiation received by humans 0.1 rad/P/yr
• Max permissible Radiation exposure
Man 5 rad/P/yr
Pregnancy 0.5 rad/P/yr
[0.5 REM/ 5 MSV

SWIMMING POOL SANITATION

• Area Per Swimmer 2.2 sqm (24 ft³)
• Filtration < 6 Hours (Rapid SF), 15% replaced
• pH 7.4–7.8
• Chlorination ≥ 1–0 ppm
• Bacterial Quality

WASTE DISPOSAL
Types of Waste
• Refuse: Solid Waste from Room, Street, Industries
• Garbage: Solid Waste from Kitchen
• Sewage: Liquid Waste with Excreta
• Sullage: Liquid Waste without Excreta

Refuse Disposal
Methods of Disposal-
1.Insanitory Methods:
• Hog Feeding – Feed to Pigs
• Stacking – Pilling Up of Refuse and Cowdung
• Salvaging – Screen Refuse Dumps
• Dumping – Refuse Thrown in Open Areas
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Light, Sound, Housing, Radiation, Waste Disposal

2. Sanitory Method:
a. Composting: It is an integrated method comprises of refuse + night soil
2 Types:
• Bangalore Method – Anaerobic Hot Fermentation
• Indore Method – Aerobic
b. Sanitary Landfill: Controlled Tipping Method
• most sanitary method
• multiple layers of soil and refuse which then compressed
• it is of 3 types:
– trench method
– ramp method
– area method

Fig. 1: Sanitary Landfill

c. Inceneration: Hot Temp. and Dry Oxidation
• It decreses both wt. and volume of sewage.

Sewage
• Composition – 99.9% water & 0.1% solid faecal matter
• Dry Weather Flow – Average Amount of Sewage Flow in 24 Hours

Strength of sewage – 3 methods to measure it

A. BOD [biological oxygen demand] – widely used amount of oxygen adsorbed by the sewage in 5 days at 20°c
units – g/l
2 methods: dilution method
manometric method
Inference –
Strong sewage - > 300 g/l
weak sewage - < 100g/l

B. COD [Chemical Oxygen Demand] – Most Popular

Oxygen Demand Equivalent to that in Organic Sample
Chemical Use – Potassium Dichromate

C. SS [Suspended Solids]
Inference –
Strong Sewage - >500Mg/L
Week Sewage - <100Mg/L
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SANITATION BARRIERS – 6 F’s

Fig. 2: Sanitation Barrier

SEWAGE DISPOSAL METHODS:

1. sea outfall
2. land treatment
3. river outfall
4. oxidation ponds [redox ponds/sewage lagoon/waste stabilisation pond]
5. oxidation ditches
6. modern treatments – 2 types

Primary T Secondary T.
Screening Aerobic Oxidation (Tfm/Activated Sludge)
Grit Chamber S. Sedimentation
P. Sedimentation Sludge Digestion

Excreta Disposal
1. Unsewered conservency System (Service Type Latrines)
• Pail Type L.
• Bucket Type L.
2. Sanitary Latrines (Non-Service Type Latrines)
• Bore Hole L.
• Dug Well/Pit L. PRAI L.
• Water Seal L. RCA L.
• Aqua Privy Sulabh Shauchalaya
• Septic Tank
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Light, Sound, Housing, Radiation, Waste Disposal

Fig. 3: Water Seal Latrine

Fig. 4: Water Seal Latrine

SEPTIC TANKS
Ideal Retention Period – 24 Hr.
Digestions:
• Aerobic – Outside Tank [Effluent]
• Anaerobic – Inside Tank [Scum & Sludge]

CAMP, TEMP USE

• Shallow Trench L.
• Deep Trench L.
• Bore Hole L.
• PIT L. Fig. 5: Dug Well

Fig. 6: Septic Tank

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Medical Entomology

VECTORS DISEASE [S]

Sand Fly [Phlebotamus] Kala Azar, Oriental Sore, Changuinola V, Sicilian
V, Oraya fever
Fever, Sandfly Fever, Chandipura V, Naples V etc
Tse tse Fly [Glossina] Sleeping sickness of Africa, (IOC → DDT)
Reduviid Bug [Triatominae] Kissing Bug / Assassin Sleeping sickness of America (CHAGAS Disease)
bug

Rat Flea [Xenopsylla] Plaque, Endemic typhus, Chiggerosis

Soft Tick Q Fever Relapsing Fever, KFD [outside India]
Hard Trick KFD [in India], Tick paralysis, Tick Encephalitis,
Babesiosis, Congo Fever, Tularemia, Tick
Hemorrhagic Fever
Louse Epidemic Typhus, Trench Fever Relapsing Fever,
Pediculosis
Black Fly [Simulism] (Flight range ~ 100 miles) Onchocerciasis

Fig. 1: Flea, Sandfly, Housefly

Anopheles Culex Aedes Mansonia

Malaria L. filariasis, Dengue Brugian Filariasis
JE Chikungunya
West Nile fever Yellow fever
Zika virus
Rift valley fever
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Breeding Habitant
Anopheles → Sophisticated M. Clean water
Culex → Nuisance Mosquito Dirty Water
Aedes → Tiger Mosquito Artificial Collection of Rain water
Mansonia → Aquatic Plants

Anopheles Culex Aedes Mansonia

Eggs Boat shaped Small Single Star
(lateral Floats) clusters Cigar shape shaped
clusters
Larvae Rest parallel to Rest at an angle to water surface [Si- Attached to roots
water Surface phon tube present] of Aquatic plants
[No siphon tube]
Adult

Sit at 45° Hunch back Hunch back

Straight posture Posture
body Spotted
wings
Flight 3-5 Km 11 Km 100 m
Range

Fig. 2: Anopheles Fig. 3: Culex Fig. 4: Aedes

MOSQUITO CONTROL MEASURES

• Life span of Mosquito
• 8-34 Days

PHYSICAL
1. Source Reduction → Overall best → Primordial
2. Mosquito Nets → Size of mesh → 0.0475 inch
[No. of Holes/sq.inch → >150]
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Medical Entomology

Chemical
1. DDT Anti Adult measure Nerve/contact poison
2. Pyrethrum [Natural] ACh'ase inhibitors
3. Malathion [least toxic]
4. Paris Green Anti larval measure Stomach poison
(contains Cu Aceto- Arsenite)

Biological
A. Larvivorous fishes
Gambusia Affinity for Anopheles Larvae
→ Lebister
→ Poecilia
B. H14 Bacillus thuringiensis
C. Coelomyces → Fungus
D. Toxorhynchitis → Mosquito
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SOCIAL SCIENCES & HEALTH

Definitions and Concepts

SOCIAL SCIENCE & HEALTH

Definitions & Concepts
Society → A group of individuals who have organized themselves & follow a
particular way of life
Social Structure → The pattern of interrelationships b/w the individuals of the society
Socialization → Process by which any particular individual gradually acquires culture
& becomes part of a social group
Community → Asocialgroupwithdefinedboundaries&commonvaluesofInterest

Social Sciences → Scientificexaminationofthehumanbehavior

Studied under
1. Economics
2. Political Science
3. Sociology Behavioral Sciences
4. Social Psychology
5. Social Anthropology

Anthropology → Study of Physical, Social & Cultural history of men

Social Pathology → Study of Social problems which undermine the social, psychological
or economic health of population
→ Describes relationship b/w Disease & Social conditions
→ can be uncovered by doing social serveys
Social Constraints → Poverty
→ Migration
→ Industrialization
Social Evils → Smoking, Alcoholism
→ Casteism, Gender bias
→ Child labour, Prostitution
Social Deviation → Drug abuse
→ Delinqency
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→ Suicide
Culture → Learned behavior, which is socially acquired [not present from
birth]
Acculturation → Mixingof2cultures[“Culturalcontact”]occursby
→ Education
→ Trade & commerce
→ Marriage
→ Conquest of one country by another

Fig. 1: Acculturation
Customs → Established patterns of behavior relevant for a particular
social setting
Folkwares → Less stringent customs [less vital areas of conduct]
Mores → More stringent customs [Purdah System]

Group Dynamics
Crowd Come Together Temporarily
No Organisation
No Leadership
Mob CommonInterest
LeaderForceThemIntoAction
Unstable, No Organisation, More Emotional
Herd Crowd With A Leader
All Follow Leader Without Questioning
Band Community Of Few Families Living Together
Oranised, Pattern Of Life

Theories of Disease Causation in Sociology

1. Marxist Theory → Diseaseoccursinasocietyduetoputtingprofitaheadofheath
2. Parsonian Theory → Disease occur d/t social constraints which arise d/t social demands
3. Feminist Theory → Disease occur d/t Role of Women enforced by men
4. Foucaldian Theory → Disease occurs so that population is segregated into groups, making them easier to
control
5. McKneown Theory Of TB → Whatever reduction of incidence /prevalence of TB is only d/t
Socioenvironmental conditions.
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Social Psychology

SOCIAL PSYCHOLOGY
Opinion → TEMPORARY PROVISIONAL views on any point of debate
→ SUBJECTIVE
BELIEF → PERMANENT , STABLE , ALMOS T UNCHANGEABLE views
→ SUBJECTIVE
Attitude → MORE or Less Per moment ways of Behavior, Based on
→ Objective Organization of beliefs on Object/Person/Situtation
Habits → Accustomed ways of doing things
→ Acquired through repetitions
→ Automatic performed in special circumstances
Emotions → Strong feelings that motivate human behavior (MC type
emotions → FEAR)

Learning
• Any relative permanent behavior change that occur dlt practice/experience
• Learning Types Associations
C ognitive K nowledge
A ffective A ttitudes
P sychomotor S kills

Mental Retardation
Mental Age
• IQ level = x 100
Chronological
• IQ < 70 = Mental retardation
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Family Systems in India

FAMILY SYSTEMS IN INDIA

Family Cycle

1. Formation → From Marriage Till 1st Child Birth

2. Extension → From 1st child birth Till last child birth
3. Completed Extension → From last children Till 1st child leaves home
4. Contraction → From 1st child leaves Till last child leaves home
home
5. Completed Contraction → From last child leaves Till Death of 1st spouse
home
6. Dissolution → From death of 1st Till death of survivor
spouse [Extinction]

FAMILY TYPES
Nuclear Family
• One Married couple with/without dependent children

Joint Family
• More than one married couples with their children living in the same house hold, Males related by blood
• Common Pool of Income + common Kitchen + common Property +
• Authority vested in a senior member

3 Generation Family
• Household with members of 3 successive generations
• Type of Joint family
• Males related by blood [In joint family also]

New Family [RCH]

• Family with marriage duration < 10 yr

Complex Family
• Family structure involving > 2 adults
• Extended family or Polygamy
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Communal Family
• All members of the family play a defined role in the management of Family
“Division of LABOUR”

Conjugal Family
• Nuclear family, Where relationship focused inwardly & ties extended to kin are voluntary

Broken Family
• Both Parents Are Separated or Death Has Occurred of One/both Parents

Problem Family
• Family lags in Progress behind rest of the community
• D/t relationship problems, poverty, Illness.
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SES, Social Security

SOCIO ECONOMIC STATUS & SOCIAL SECURITY

Socio Economic Status Scales [SES Scales]
1. Urban 2. RURAL
• Modified Kuppuswami scale • Udai Pareek Scale
• KulShrestha Scale • Modified BG Prasad Scale
• Srivastava Scale • Radhukar Scale
• Jalota Scale • Shirpurkar Scale
3. Students’s Scale 4.Non- Indian
• → Bhardwaj Scale • Hollingshead Scale
• Henderson scale

Modified Kuppuswami Scale

Components
1.Income → Family members
2.Education → Head of Family
3.Occupation → Head of Family

• Upper class → 26-29

• Upper Middle → 16-25
• Lower Middle → 11-15
• Upper Lower → 05-10
• Lower class → 00-04

Social Security Measures for Industrials Workers in India

• The Workmen’s compensation Act 1923
• The Factory Act 1948
• The ESI Act 1948
• The Coal Miners provident fund & Bonus act 1948 The Employee’s PF Act 1952
• The Central Maternity Benefit Act 1961
• The Family Pension Scheme 1971
• The Old age Pension Scheme 1995.
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OCCUPATIONAL HEALTH
Pneumoconioses

OCCUPATIONAL HEALTH
I. Physical Agents
Heat → Hyperpyrexia, Exhaustion, Stroke
Cold → Chill Blains, Frost Bite
Light → Cataract, Miner's nystagmus
Pressure → Caisson's Disease
Noise → Deafness
Radiation → Leukemias, Aplastic Anemias
Others → Burns, Injuries, Accidents
II. Chemical Agents
Gases → Poisonings
DUSTS → PNEUMOCONIOSIS
Metals → Heavy metal Poisonings
Chemicals → Poisonings [Solvents]
III. Biological Agents Brucellosis Anthrax Leptospirosis
IV. Occupational Dermatitis (Mainly in metal type of exposure)
V. Occupational Cancers
VI. Others → Neurosis, Hypertension

PNEUMOCONIOSES
• D/t occupational exposure to dust
• < 0.5 µ → Always in Brownian motion [Moves in & out]
• 0.5 - 3 µ → Most dangerous particle size
3 - 5µ →Trapped by mid respiratory tract
5 - 10µ →Trapped by upper resp. tract
> 10µ → Fall on machine
– Common Pneumoconiosis
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D/t MC Disease Association MC Occupational Association

Silicosis Silica Dust TB Cement, Glass, Bauxite miners,
Industry
Anthracosis Coal Dust Progressive Massive Fibrosis Coal Miners
Asbestosis Asbestos dust Mesothelioma, Lung cancer Cement, Shipyards
Byssinosis Cotton Fiber Dust Monday Chest Tightness Textile Industry
Bagassosis Bagasse Sugar Mill
Thermoactinomyces sacchari

D/t MC Associated Organism

Farmer’s Lung Mouldy Hay Micropolyspora faeni
Compost Lung Compost Aspergillus
Bird Fancier Lung Bird droppings
Siderosis Iron
Stenosis Tin

• MC micro organism associated with Bagassosis

Thermoactinomyces Sacchri
• MC /MC Cause of Death / MC Cause of Disability SILICOSIS
•
• Notifiable Diseases under factory Act’ 1948
1. Silicosis
2. Anthracosis
3. Asbestosis
4. Byssinosis
• Snow Storm appearance on CXR → Silicosis
• Byssinosis → MC seen in SPINNERS
• Bagasse’s control in sugar mill → 2% Propionic Acid spray is used
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Other Occupational Diseases

LEAD POISONING/PLUMBISM/PAINTER’S COLIC

• MC source in India = Petrol/Gasoline/ Vehicular exhaust
• MC mode in India = Inhalation
• C/F

Burtonian’s line: Blue line on gums [lead sulphide - PbS] d/t inorganic
Pallor: 1st sign, most consistent sign Lead Exposure
Wrist/Foot drop: nerve palsy
Colic
Encephalopathy (ORGANIC LEAD EXPOSURE)

Screening Test = CPU [coproporphyrin in urine] (Lead exposure) = Cut OFF > 150 Mcg/L cut offs

Diagnostic Test
• ALAU [Amino Clavulanic Acid in Urine] → > 5mg/L (Lead absorption)
Lead levels in Blood → > 70 µcg/100 m (Symptoms appear)
Lead levels in Urine → > 0.8 mg/L (Lead exposure and absorption)
– Mainly RBC’s Affected

Basophilic Stippling
RBC’s
Microcytic Hypochromia

Fig. 1: Basophilic Stippling

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• Rx OC:
1. EDTA (with DIMERCAPROL)
2. Penicillamine
• Prognostic Test PBS [Peripheral Blood Smear]

OCCUPATIONAL CANCERS
• MC Occupational Cancer = Skin [Squamous Cell Carcinoma]
• PVC [Poly Vinyl Chloride] Exposure = Angio Sarcoma Liver

Asbestos → Mesothelioma
Benzene → Leukemia

Benzidine
Bladder cancer [Transitional cell carcinoma]
N2/Aniline
Nickel, Chromium, wood dust → Nasal sinus carcinoma

RADON, Beryllium
Lung carcinoma
Silica, Cadmium

CAISSON’S DISEASE / DECOMPRESSION SICKNESS

• Affects deep sea drivers
• d/t Low pressure

GASES:
• NITROGEN
• HELIOX
• TRIMIX

N2 Effervescence Air Expansion

↓ ↓
Bends Baro Otitis
Chokes Baro Sinusitis
Prickles Baro Odontalgia
Paralysis [most severe] Emphysema [most Severe]
Aseptic Bone Necrosis Abdominal distension

Rx OC
1. Recompression chambers
2. Hyperbaric O2 therapy
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Other Occupational Diseases

ERGONOMICS
Science where we study people’s efficiency in their working environment.

Pre Placement Examination Post Placement Examination

• Right man in Right Job • Regular periodic Examination
• Fitting Job to worker • Annual- Most occupational Exposures
• Every 2m- Radiation exposure
• Monthly - Lead, Dye, Radium
• Daily- Dichromats
PRIMARY PREVENTION SECONDARY PREVENTION

SICKNESS ABSENTIISM
1. Medical causes Economic
2. Non sickness causes Social
Other
• 8-10 days/person/year.
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Occupational Health Legislations

OCCUPATIONAL HEALTH LEGISLATIONS

The Factory Act 1948
• Factory → ≥ 10 persons working together with power
or ≥ 20 persons working together without power
Defense
Mines
• Not applicable on Railways
Eateries/Food Joints
• Child → 0-14 yrs [Employment prohibited <14 yrs]
• Adolescent → 15-18 yrs
• Work Hour Duration → 9 hrs/Day
48 hrs/week
60 hrs/week [overtime]
• 1 Safety Officer/1000 worker
1 Welfare Officer /500 workers
1 canteen/250 workers
1 creche/30 female workers
• 29 Notifiable Diseases
• Per capita space > 500 cu. ft.

The ESI Act 1948

• ESI → Employees State Insurance
• Ministry → Union Ministry of Labour
Chair person → Union Minister of Labour
• Contribution → Employer → 3.25% of wages
Employee → 0.75% of wages
• Center: State → 7:1
• Coverage
– All Non seasonal factories where ≥ 10 persons
Fig 1: ESI
All other factories where ≥ 20 persons
– Income < 21,000/- per month
Defence
Not applicable on Mines
Railways
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Benefits
1. Medical Benefit → Full medical care
2. Sickness Benefits → 70% wages x 91 days
Extended sickness benefit → 80% wages x 2 years
Enhanced Sickness benefits → 100% wages x 7 Days [Vasectomy] x 14 Days [Tubectomy]
3. Temporary Disablement Benefit → 90% wages till recovery
Permanent Disablement Benefit → 90% wages [worked by Medical Board]
4. Maternity Benefits → 100% wages x 26 weeks
5. Dependence Benefit → 90% wages as pension
6. Funeral Expenses → Up to Rs 15,000

The ESI ACT’ I948

ESI 2.0 ; ELEC. HEALTH RECORDS
Senior Citizen OPD
* ABHIYAN INDRADHANUSH
VIOLET ______SUNDAY
INDIGO ______MON
BLUE ________TUE
GREEN _______WED
YELLOW ______THU
ORANGE ______FRI
RED __________SAT
Bedsheet color change sequence
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BIOMEDICAL WASTE MANAGEMENT

BMW in India

INTRODUCTION
• Biomedical waste Management in India covered by EPA [ Environment Protection Act 1986]
– Section 6,8,25
• 4 SCHEDULES
SCHEDULE I → Categorization, Segregation, Processing, Treatment, Disposal
SCHEDULE II → Standards for treatment& Disposal
SCHEDULE III → Authorities & Duties
SCHEDULE IV→ Labels for BMW bags, containers
• Under Ministry of Environment& forests and climate change

LATEST GUIDELINES 2017-2018

• Earlier → BMW Mx 1998
10 categories, 4 color-coded bags & disposal
↓ ↓ NOW MADE
• 2017-18 → Discarded 4 categories& disposal
• YELLOW CATEGORY
Placenta
1. Human anatomical waste Appendix
Gall bladder Incineration (1200°)
Amputations Plasma Pyrolysis
DEEP BURIAL (esp. for placenta at PHC)
2. Animal waste Animal House

6. Soiled waste Gauge Pieces

[cotton/cloth] Bandages Dressings INCINERATION/
Swabs Plasma Pyrolysis
DEEP BURIAL
Disinfectants
10. Chemical waste Production of
Biologicals INCINERATION/
Plasma Pyrolysis
ENCAPSULATION
5. Discarded Medicines Expired medicines
Cytotoxic Drugs
8. Liquid chemical waste → Chemical Rx F/b Drain
[cleaning, House keeping, disinfection activities]
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3. Microbiological, Biotechnological, lab waste Non-chlorinated

[Cultures, Live vaccines, Toxins, Other Biological] Chemical Rx F/B
Bed Linen, Mattresses, Bedding Incineration

RED CATEGORY
7. Solid/contaminated [Recyclable] waste [Plastic/Rubber] Autoclaving/Microwaving / Hydroclaving
Tubings
Catheters
Canales
DESTRUCTION/SHREDDING
↓
ENERGY RECOVERY/FUEL OIL/
ROAD MAKING

WHITE CATEGORY
4. → Wasted sharps → AUTOCLAVING /
Needle, Sx blades, Scalpels DRY HEAT
↓ f/b
SHREDDING/
MUTILATION/
ENCAPSULATION
↓ f/b
IRON FOUNDRIES/
LANDFILLS/SHARPS PITS

BLUE CATEGORY
Glassware Orthopedics CHEMICAL Rx/
Metallic Body implants ENT AUTOCLAVING/
Dental HYDROCLAVING/
Cardio thoracic MICROWAVING
Vascular Sx F /b recycling

METHODS
INCINERATION
• Temperature → >1200°C (NO PRE-TREATMENT)
• Principle → High temperature + Dry Oxidation
• Combustible matter > 60% Non-combustible Solids < 05%
Non - Combustible fires < 20 %
Moisture content< 30%
Contraindicated are
1. PVC Plastic Waste Angiosarcoma of Liver
2. Pressurized Waste Explosion can occur
3. Heavy metal Waste Lead, Cadmium, mercury Poisoning
4. Reactive Chemical Waste Silver [X Rays]
5. Radioactive waste Sea burial is recommended
6. RED Bag
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Biomedical Waste Management BMW in India

AUTOCLAVING
• Temperature in India → 121°C15psi (>45 min)
135°C
149°C
• Principle → Steam under high pressure → Check sufficiency of Autoclaving → GBS
[Geo Bacillus Stearothemophilus]

Fig. 1: Autoclave

HYDRO CLAVING
• Temperature → 121°C or 132°C
• Principle → Steam under pressure
• Check Sufficiency → Bacillus Subtilis

MICRO WAVING
• 12 nm, 2450 MHZ
• Principle → Generation of CONUECTION CURRENT in heated water molecules
• Check sufficiency → Bacillus atrophaeus

ENCAPSULATION
• Filling containers with BMW & Immobilization materials
[Foam, Sand, Cement, Clay]
↓
Seal the containers

PLASMA PYROLYSIS → >1200°C

INERTIZATION
• Large Volumes Of Toxic BMW
↓
Non Toxic waste [Inert]
• 15% cement + 15% Lime + 65% BMW + 5% WATER
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• BMW mixed with cement

↓
Rotating Auger [Heating &Shredding]
• Non Burn, Dry thermal process
• ↓ Weight by 20-25%
↓ Volume by 80%
• Used for sharps waste, Infectious waste
• C/I for Radiological, Cytological, Pathological waste

Fig. 2:SFT
DRY HEAT → >185°C, HOT AIR OVEN 160°
COMPOSTING → Land + cow dung [GOBAR] + WASTE

VERMI- COMPOSTING
• Earth worms [Eisenia foetida] + Land + Mature cow dung [KHAD] + Coconut Husk
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COVID-19 BMW Management

Central Pollution Control Board (CPCB) guidelines - VERSION 5

Isolation Wards:
• Double layered bags for collection, storage & handling
• Bags should be labelled as “COVID-19” waste
• Wet & dry wastes should be collected in leak proof bags and must be sprayed with sodium hypochlorite
spray
• Yellow bags should not be used for collection of general waste, compostable bags should be used for wet
waste
• Inner as well as outer surface of Bins / Containers / Trolleys must be sprayed with 1% Hypochlorite
spray.

Red Category Yellow Category

Syringes IV Sets Anatomical W., Soiled Waste
PPE’s, Hazmat Suit Discarded Medicines
Googles, Face Sheild Head And Shoe Cover
Plastic Overall Masks (N95, Triple Layer)
Splash Proof Apron Non-Plastic Overall
Nitrile Gloves Tissues/Masks/Toiletries of patients
Disposable Linen Gowns

General Guidelines
• Double Layered bags
• Bins labelled as COVID-19
• Bags, trolleys Labelled as COVID-19 waste
• Record maintenance of COVID waste
• Disposal Area & Bins / Trolleys should be disinfected with 1% Hypochlorite

Common Disinfectants
• 1% Hypochlorite
○ 10 minutes contact should be there
○ Always freshly prepared solution should be used
• 70% Isopropyl / Ethyl Alcohol
• Delicate Instruments
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Terminal disinfection
• Hydrogen peroxide based disinfectant
• Fogging x 30 minutes

SPECIFIC WASTE DISPOSAL

1. HIV Infected Maternal Disposal
→ Rx with 1% Hypochlorite
↓
Categorize
↓
Disposal
2. Mercury Disposal
→ Recollect → Recycle → Reuse[R3] (Collect with cardboard, put in water)
3. e-waste Disposal → Recycle
4. Blood spil l → 1% Hypochlorite [neutralizer] → Drain
5. TB SPUTUM → Incineration(Best), Burning, Autoclaving, Boiling, 5% Cresol
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DISASTER MANAGEMENT
Definition and Concepts

Disaster
• An occurrence that causes damage or ecological disruption or the loss of human life or deterioration of
health or health services ON A SCALE sufficient to warrant an extra ordinary response from outside of
that community or area.
• COLIN GRANT
Any occurrence or catastrophe causing injury and/or illness simultaneously to ≥ 30 persons who require
hospital emergency services

Disaster Mitigation
• Prevention of conversion of hazard/risk into disaster situation [to minimize the damage]

Surge Capacity
• Ability of a health system to respond to disaster situations

TYPES OF DISASTERS
Natural Man-Made
Geological – Earthquakes, volcanos Wars
Hydrological – Floods, Tsunamis Accidents
Climatological – Droughts, Fires Civil disturbances
Biological – Epidemics Refuges
Extraterrestrial – Meteorites

DISASTER CYCLE

Fig. 1: Disaster cycle

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Health & Medical Relief

1. Primary phase [0-6 hrs] → First aid, medical care
Transportation,
2. Secondary follow up [6-24 hrs] Sanitation,
Immunization
Food, clothing,
3. Tertiary clean up [1-60 days] Shelter, Social services,
Employment
Rehabilitation
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Triage, PDP

• Classification of victim of disasters

• On basis of likelihood of survival
• Done at the site of disaster

TRIAGE
• TRIAGE: CATEGORISATION of Victims of Disaster
• TRIGE SIEVE: Seperate DEAD FROM WALKING & INJURED
• TRIAGE SORT: Remaining Casualties are categorised

CATEGORIES
Priority
1. Highest → Immediate Resuscitation or Limb/Life saving Sx 0-6 hr. - RED
2. High → Possible Resuscitation or Limb/life saving Sx 6-24 hr. - YELLOW / BLUE
3. Low → Minor injuries [non life threatening], Ambulatory - GREEN
4. Least → Dead & Moribund [about to die] BLACK

Color coding → TAGGING

Types of Triage
START → Simple triage And Rapid Treatment
→ In remote inaccessible areas of country, done by LAY PERSONS
REVERSE TRIAGE → minor injuries must be given highest priority
→ In wars, Battles

PDP [Post Disaster Phase]

• MC disease reported is Acute Gastroenteritis

MCQ. Not seen in PDP?

Typhoid Scabies Leishmaniasis URI
Cholera TB Leptospirosis

• MC Vitamin deficiency → Vitamin A [B3, C]

• Vaccines in PDP → All C/I except Measles
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Q Which Vaccines are C/I in PDP by WHO? ALL are C/I

Ans. Typhoid, Cholera, Tetanus toxoid [all others are relatively C/I] only Measles is allowed
Q Which Vaccine is mandatory for medical persons ?
• Typhoid, cholera, Tetanus toxoid

Most important preliminary step in PDP → Chlorination

– residual Cl2 in drinking water → ≥ 0.7 mg/L [ppm]

DM in INDIA
• National Disaster Management Authority
[NDMA] - chairperson → Prime Minister
• Nodal Ministry → Home Affairs
• Nodal center → District
• National Institute of Disaster Management [NIDM]
– Under Home Affairs
– Under Union Home Minister
– National Disaster Response force Includes CRPF, BSF, ITBP, CISF
• Maximum mortality is reported from Hydrological Disaster (Worst Man-made disaster → Bhopal Gas
Tragedy, 3rd Dec 1984 Methylisocyanide exposure)
• World Disaster Risk Reduction Day → 13th October
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GENETICS & HEALTH

Genetics

GENE → A Sequence of DNA/RNA which codes for a molecule with a particular function.
GENOME → Sum total of genetic information of an individual, encoded in the structure of DNA.
GENOMICS → The study of human genome.
GENE THERAPY → Introduction of a gene sequence into a cell so as to modify its behavior.
DNA TECH → Development of new Dx technique based on DNA E.g. Restriction enzymes.

MENDELIAN INHERITENCE

Autosomal Dominant Autosomal Recessive

Achondroplasia Alkaptonuria

Huntington’s Chorea Albinism

Neurofibromatosis Cystic Fibrosis

Familial Polyposis Coli Tay Sach’s Disease

Marfan Syndrome Phenylketonuria

Retinoblastoma Galactosemia

Abo Blood Group System Haemoglobinopathies

Polycystic Kidney Hirschsprung Megacolon

H. Spherocytosis Maple Syrup Urine Disease

Hyperlipoproteinemia

MENDELIAN INHERITENCE
Sex Linked Dominant
• Vitamin D Resistant Rickets
• Blood GROUP Xg
• Familial HYPOPHOSPHATEMIA

Sex Linked Recessive

• Hemophilia A,B
• COLOR Blindness
• DUCHENE MUCULAR Dystrophy
• G6PD deficiency
• Hydrocephalus
• Retinitis Pigmentosa.
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EUTHENICS EUGENICS
Environmental manipulation Geneticmanipulation for full expression of genes
For full expression of genes Positive Negative
E.g. Disabled friendly schools IVF Abortion
Gene Cloning Sterilization
Egg transplant Family planning

GENETIC COUNSELLING

PROSPECTIVE RETROSPECTIVE

Done to identify heterozygotes through Screen- Seeking advice when a hereditary disorder has
ing & then advise them already occurred in the family

E.g. Congenital anomaly Mental Retardation

E.g. Thalassemia Sickle cell anemia
Metabolism Errors

HUMAN GENOME PROJECT

• By Dr JAMES D WATSON (1990)
• Total no. of genes in human genome → 19000 -20000 [~19,500]

HUMAN GENOME PROJECT (HGP)

Primary Goal – To identify BASE PAIRS in DNA & TOTAL NO. of GENES
Secondary Goal – To understand Human GENOME & Complete MAPPING

01 OCT’ 1990 ------14 APRIL 2003

TOTAL BASE PAIRS – 3 BILLION

TOTAL GENES – 19,500

TECHNIQUES USED (Classical Technique)

1. MAXAM GILBERT T. – Break DNA at specific bases
2. SANGAR T.- Chain Termination

HARDY WEINBERG LAW OF GENETICS

• Law of Population Genetics
• (a+b)2 = a2+b2+2ab
• Frequency of genes remain constant from one generation to another generation

Applicable on Not Applicable on

Large Population Small Population
Static Population Dynamic Population
Random Mating Population Non Random Mating Population
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Genetics & Health

Assortative
Mating
Population
Mutation
Gene flow
Gene Drift
Natural
Selection
Fig. 1: HW Law Migration

BLOOD GROUPS IN INDIA

ABO RH
O 40% Rh + 77%
B 33% Rh - 23%
A 22%
AB 05%

Fig. 2: ABO system

BOMBAY BLOOD GROUP

• Cannot express ABO d/t absence of H antigen
• Cannot receive blood except Bombay blood group
• 4 persons/million population
• Aka HH Blood group
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Fig. 3: Universal Donor, Recipient

RHESUS IMMUNISATION
Icterus ---Hydrops Fetalis

MOTHER Rh -ve
Second Delivery
FETUS Rh +ve

First Delivery it can occur if

• H/O Abortion
• H/O Mismatched Blood Transfusion

Anti D Immunoglobulin
• 28 Week POG
• < 72 h of Delivery

AMNIOCENTESIS INDICATIONS
1. Age of women > 35 yrs
2. H/o Down’s syndrome Chromosomal defects Metabolic defects
3. Sex determination is warranted

Fig. 4: AMNIOCENTESIS INDICATIONS

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MENTAL HEALTH
IQ Level

INTELLIGENCE QUOTIENT (IQ)

• → Score derived from Standardized tests
• → STERN’s IQ Test

Mental Age
IQ = x 100
Chronological Age
= IQ Points
• useful till 15 yrs
Q. 15 yrs old child has mental age 5 yrs, IQ → ?

5
IQ = x 100 → 33 → Imbecile
15

IQ Classification
Idiot → 0-24
Imbecile → 25-49
Moron → 50-69
Borderline → 70-79
Low normal → 80-89
Normal IQ → 90-109
Superior → 110-119
Very Superior → 120-139
Near Genius → > 140
Mental Retardation Classification
Normal IQ ≥ 70
Mild MR 50-69 → 70% [MC]
Moderate MR 35-49 → 20-30%
Severe MR 21-39
Profound MR ≤ 20
MCC MR in India → Down’s syndrome
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Mental Health Disorders in India

• MC MH Disorder
– Unipolar depression (MC)
– Alcohol disorder
– Schizophrenia
– Bipolar disorder
• MCC Death among MH Disorder : Alzheimer’s & Other Dementias
• DALY’s lost d/t u. depression → 64,963 [1400 DALY’s lost /1,00,000 population]
• MC substance abused → Tobacco
– MC Narcotic Substance abused → Cannabis
• Mental morbidity → 18-20/1000 population

Fig. 1 : Cannabis

SUBSTANCE USE DISORDERS

DRUGS (WHO) – Any substance, when taken, which modifies ONE/MORE of function(s)

DRUG ABUSE – Persistent or excessive use not inline with acceptable medical practice

DRUG ADDICTION - State of Periodic/Chronic intoxication due to repeated consumption

Continue the drug and acquire it
Increase Dose
Psychic & Physical dependence
DRUG DEPENDENCE – STATE
Compulsion to take the DRUG to
Avoid withdrawal symptoms
Enjoy the pleasurable effects
TOLERANCE ±
≥ 1 DRUGS

Fig. 2 : Suicide

SUICIDES In India
→Rate → 12 / 100000 population/year
→ MC mode → Hanging
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National Mental Health Programme 1982

Aims
1. Prevention & Rx of MH Disorders
2. Use of MH technology to improve health
3. Application of Mental health principles in development & to improve Quality of life
4. Increase Human resources in Mental subspecialities

Objectives
1. Availability & accessibility for ALL
2. Application of MH Knowledge in general H . care
3. To promote community participation in MH

DmHP [DistRict meNtAL HeALtH PROG.] 1996

BELLARY MODEL
• EARLY DETECTION & TREATMENT
• TRAINING
• IEC
• MONITORING: REPORT WRITING

Legislation
The Mental Health Act 1987 → The MH Care Act 2011

mH DisORDeR PReveNtiON AND cONtROL

mental Health care Act,2017 [cRPDOP – United Nations]
• Decriminalisation of suicide attempt
• MENTAL Health disorder / illness Minus M. Retardation
• Good quality MH care, ACCESSIBLE, AFFORDABLE
• FREE Legal services
• Medical professional – NOT liable
• NO ECT
• NO Solitary Confinement
• CMH AUTHORITY
• SMHA
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HEALTH EDUCATION & COMMUNICATION

Process and types

HEALTH COMMUNICATION PROCESS

• Exchange of Ideas, Feeling & Information in the field of health
• Components:

Fig. 1 : Communication process

HEALTH COMMUNICATION
Types of Communication
1. ONE way C VS TWO WAY C
DIDACTIC SOCRATIC

2. VERBAL C VS NON-VERBAL C
FACE TO FACE C INDIRECT INTERACTION

3. FORMAL C VS NON-FORMAL C
LINE OF AUTHORITY GRAPE-WINE C

4. VISUAL C
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APPROACHES FOR HEALTH COMMUNICATION

Individual Based Group Based Mass approach Based
Home Visits Lecture TV
Personal Contact Demonstration Radio
Personal Letters FGD [Focus Gr. Discussion] News
PD [Panel Discussion] Printed matter
Symposium Posters
Work Shop Exhibition
Conference Internet
Seminar Folk methods
Role play Direct mailing
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Health Communication
Methods

LECTURE [CHALK & TALK METHOD]

• 1 Person addressing audience
• Group Size [recommended] < 30
• Duration [recommended] < 15 – 20 mins

Fig. 1: Lecture
• Advantage → can cover larger audience in lesser frame of time
→ can communicate more things
• Disadvantage → Learning is passive
No Q & A [Questioning & Answering]

FGD [FOCUS GROUP DISCUSSION]

• Very effective method
• Discussion on health among 6-12 persons (1 is Group leader)
(1 is Recorder)
– Manual/Electronic
– has to draw diagram

Fig. 2 : Focus Group Discussion

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Sociogram
• Interaction b/w participation in FGD
• Advantages
Can make discussion more healthy by promoting/ restricting persons to participate in discussion

Fig. 3 :Sociogram

PANEL DISCUSSION [PD]

Discussion among ‘4-8 experts in front of audience’
• No specific order of speeches
• No set speeches
• News channel discussion

Fig. 4 : Panel Discussion

WORKSHOP
• Series of 4-5 meetings ‘to impart training or skills’ to participants
• Group work, Group Discussion, Plan of Action
• Help from consultants & Resource persons taken

SYMPOSIUM
• Series of lectures’ by ‘experts’ in front of ‘audience’
• No discussion at all among experts
• Specific order of speeches present
• Set speeches present
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Health Communication Methods

ROLE PLAY/SOCIO DRAMA → STREET PLAY

• Situation dramatized’ by a group of people in front of audience
• Followed by discussion
• Ideal audience Size → < 25

CONFERENCE/SEMINAR
• Combination of methods at ‘Big/Macro level’ [University, State, National level]

IPC -INTER PERSONAL COMMUNICATION/

• FACE-TO-FACE/ONE-TO-ONE COMMUNICATION]
• Most effective method even better than FGD

DELPHI METHOD

HC METHODS - DELHI METHOD

Geographically dispersed experts
↓
Repeated Exchange of Questionnaires
↓
Consensus Generation → DECISION MAKING

Systematic Interactive Forecasting, Method

DEMONSTRATION
Seeing is believing
• Principles
Learning by doing
E.g. : ORS preparation

Fig. 5: DEMONSTRATION
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FLANNEL GRAPH
• → Series of Photographs pasted on a piece of cloth in correct chronological sequence
E.g. Life cycle of Plasmodium

SPIKES TECHNIQUE
Communication of cancer Diagnosis & Prognosis (or any adverse outcome)
P Protocol of 6 steps
S Set up interview
P Perceptions
I Invitation to explain
K Knowledge
E Emotions
S Summary & Strategy
Best used for Breast cancer

GATHER APPROACH
• Used for contraceptive counseling in RCH
G Greet
A Ask
T Tell
H Help
E Explain
R Rrturn visit
(Older name → Cafeteria Approach)

Classification of Health Communication Methods

DIDACTIC One-way Communication SOCRATIC Two-way communications

Lecture FGD

Flannel Graph PD

TV Symposium

Radio Roleplay

News Print Workshop

Posters IPC Seminar/Conference

Charts Demonstration

Banners SPIKES

Pamphlet GATHER
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Doctor - Patient Communication

LEVELS 3
1. Intellectual → based on literacy & comprehension of doctor & patient
2. Emotional → Bonding b/w Doctor & patient
3. Cultural → Doctor & patient from same Region| Religion| Socioeconomic status

TYPES 4
1. Default → neither doctor, nor patient has focus
2. Paternalistic → Doctor is dominant
3. Consumeristic → Patient is in focus [seen in Pvt. Hospitals]
4. Mutualistic → Both doctors & patient Jointly involved in decision making

HEALTH EDUCATION
Processes by which individuals & groups learn to behave in a manner which is conducive to promotion, maintenance
& restoration of Health [JOHN M. LAST]

Approaches
1. Regulatory Approach/Managed Prevention
– Coercive/Legislative Approach
– Successful to a limited extent
2. Service Approach
– Providing health services at door step
– limited success
– Not based on felt needs
3. Health Education Approach
– Slow process but enduring results
4. Primary Healthcare Approach
– Community Involvement
– Intersectoral Co- ordination
– Radically New Approach

Principles
• Credibility
• Interest
• Participation
• Motivation
• Comprehension
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• Reinforcement
• Learning by doing
• Known to unknown
• Setting an example
• Good Human Relations
• Feed back
• Local leaders involvement

Health Education Health Propaganda

Appeals to Reason Appeals to Emotions
Thought process present No thought process

Knowledge & skill actively acquired Knowledge & skill instilled in minds
Behavior- REFLECTIVE Behavior- REFLEXIVE
Processes-Behavior centered Processes - Information centered

MASS MEDIA
• Diversified collection of Media technologies intended to reach a mass audience
• Advantages
1. Reached to large population in small time (Even in Lower literacy rate)
2. Effective Reach remote areas
3. Gets attention
• Dis Advantages
1. Mostly one way Communication
2. May not effect change of behavior

TV, Radio, News Print, Internet Most popular/effective - TV

Museums, Exhibits, Folk Media Fastest growing → internet
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HEALTH PLANNING
Definitions and Concepts

DEFINITIONS
Health Planning → Orderly process of defining community health problems, identifying unmet needs, surveying
the resources to meet them, establishing realistic Feasible Priority goals, projecting administrative action to
accomplish the programme.

Resources → Stock or supply of man power, money, materials, skill, knowledge, techniques & time that can be
drawn by a person or organization in order to function effectively.

1. Objectives → Precise, Specific PRE-PLANNED end point of all activities in a Health program
2. Target → Degree of achievement of objectives with a time line

3. Goal → Ultimate desired state in a H. programme towards which objective & resources are directed
All or None Phenomenon
Not constrained by time & resources

GOOD OBJECTIVES (SMART)

SPECIFIC – Clear, Precise

MEASURABLE – Amenable to evaluation

APPROPRIATE - Relevant

REALISTIC – Resources considered

TIME BOUND – Achievable in time frame

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PLANNING CYCLE - AORP - PIME [Mnemonic]

Fig. 1 : Planning cycle

NPC 1951 – NATIONAL PLANNING COMMISSION (NPC)

• PRIME MINISTER – Chairman
• 12th FYP 2012-2017

NITI AAYOG 2015 (Replced NPC)

NATIONAL INSTITUTE FOR TRANSFORMING INDIA
• PRIME MINISTER – Chairman
• 15 years VISION plan with 3 yr ACTION plan
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Health Planning Committees

BHORE COMMITTEE [1946] /H. Survey & Development Committee]

1 Short term plan → 1 PHC/40,000 population
Long term plan [3 PHC 75 bedded Sec. Health Unit 650 bedded Tertiary Health unit 2500
2 →
million plan] bedded
3 Social Physician → 3m/12m internship (post MBBS) in PSM
4 School health
5 Comprehensive Health care concept
a. Promotive → Primordial level
b. Preventive → Primary level
c. Curative → Secondary level

BALWANT RAI MEHTA COMMITTEE [1957]

1. Panchayati Raj Institutions [PRI’s]
2. 3 Tire Rural Health Infrastructure
Zila Parishad → District
Panchayat samiti → Block
Panchayat → Village

RENUKA ROY COMMITTEE [1961]

• Functional of School health services [SHS]
• Provision of School meals
• Medical Examination with involvement of parents

MUDALIAR / HEALTH SURVEY & PLANNING COMMITTEE [1962]

1. 1 PHC /40,000 population
2. All India Health Services (AIHS)
3. Strengthen district hospitals with specialist services

CHADDHA COMMITTEE [1963]

For maintenance phase of National Malaria Eradication Programme
1. 1 Basic health worker / 10,000 population
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MUKERJI COMMITTE [1956-66]

1. Delink Malaria & Family Planning
2. Basic Health services

JUNGALWALLAH COMMITTEE [1967] /

Committee On Integration of Health Services
1. Integration of health services in India
2. Equal pay for equal work (specialized pay for specialized work)
3. Ban on private practice by Govt. Doctors

KARTAR SINGH COMMITTEE (1973)/

Committee On MP Workers Under Health &FP
1. Multipurpose Workers
2. 1 PHC /50,000 Population
3. 1 Male Health Supervisor, 1 Female Health Supervisor

SRIVASTAVA COMMITTEE (1975) /

Group On Medical Education & Support Manpower
1. Bands Of Semi - & Para - Professional H. Workers
2. Village Health Guides
3. H. Assistants
4. ROME SCHEME [Re Orientation of Medical Education]
5. Referral Services complex
Primary Secondary Tertiary
6. Medical & Education Commission

KRISHNAN COMMITTEE (1983)

URBAN REVAMPING SCHEME

BAJAJ COMMITTEE (1986)

1. Formulation of National Medical & Health Education Policy
2. Formulation of National Health Manpower Policy
3. Education Commission
4. Health Manpower Cells

HLEG COMMITTEE (2011) /

[High Level Expert Group Committee]
1. Universal health coverage
2. 3.5 yrs MBBS Course [Actually BRHC course]
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HEALTH MANAGEMENT
HM Techniques, Inventory Control

MANAGEMENT TECHNIQUES
1. QUALITATIVE
2. QUANTITATIVE (MODERN)
3. H. ECONOMICS (MODERN)

I. QUALITATIVE TECHNIQUES
A. Organisational Design
Suited to meet current health demands and needs
Reviewed after few years according to requirement

B. Personal Management
Skillful use of resources

C. Communication
Removal of barriers

D. Information System
It includes collection, classification, storage, transmission, retrieval & display

E. Management By Objectives [MBO]

In this, subunits & units prepare own plan of action

Fig. 1: CBA
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II. HEALTH ECONOMICS TECHNIQUES

It includes cost analysis

A. CBA [Cost Benefit Analysis]

Results of a programme analysed in terms of MONETARY benefits eg. NTEP (2023-24) saved 12 m US $

B. CEA [Cost Effective Analysis]

Output of a programme analysed in terms of RESULTS eg. NTEP (2023-24) save 1.7 Million people can be
determined with help of QALY

Fig. 2: CEA

C. INPUT-OUTPUT ANALYSIS
Calculation of effects of changing the inputs (Includes CBA & CEA)

D. CUA [Cost Utility Analysis]

Cost & benefit that impacts both
– Quality of life
– Quantity of life
Use DALY & QALY for it’s analysis

E. COST ACCOUNTING
It includes basic cost structure of a health programme
Financial of resource allocation

F. CMA [Cost Minimisation Analysis]

Compare cost of different interventions to provide equivalent benefits

III. QUANTITATIVE METHODS

A. SYSTEMS ANALYSIS
Comparison of ≥2 cost effective alternatives in a h. program

B. NETWORK ANALYSIS
It includes activities & events

B1. PERT [Program Evaluation and Review Technique]

It tells about SEQUENCE OF ACTIVITIES in a health program
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Health Management HM Techniques, Inventory Control

B2. CPM [Critical Path Method]

It is the LONGEST PATH present for completion of program

Fig. 3: PERT

C. PPBS [Planning Prog. Budgeting System]

Helps resource allocation to achieve objectives in most efficient way
ZERO BUDGET APPROACH (ZBA)
– no fresh budget allocation unless previous is zero (spent)

D. WORK SAMPLING
Systemic observation & recording of work activities of individual groups in hospitals
It is either predetermined or random

E. DECISION MAKING
It means, make a decision at such level so that there is better use of resources

EVALUATION OF HEALTH SERVICES

• RELEVANCE [appropriateness/need]
• ADEQUACY [sufficient thought]
• ACCESSIBILITY [% population to use]
• ACCEPTIBILITY [culture/socially]
• EFFECTIVENESS [extent problem is alleviated]
• EFFICIENCY [utilisation of resources]
• IMPACT [overall effect]
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Strengths WEaknesses
• KNowledge: Our competitiors are pushing • Price and volume: The major stores pushng
boxes. But we know systems, networks, boxes can afford to sell for less.
prgramming, and data management. • Brand power: We can not match the
• Relationship selling: We get to know competitor’s full-page advertising in the
ourcustomrs, one by one. Sunday paper. We do not have the nation brand
• History: We have been in our town forever. name.
We have the loyalty of customers and vendors.
Opportunties Threats
• Traomomg: The major stores do not provide • The larger price-oriented store: When they
training, but as systems become more complex, advertise low prices in the not giving them good
training is in greater demand. value.
• Service: As our target market needs more • The computer as appliance: Volume buying of
service, our competitors are less likely than computers as products in boxes. People think
ever to provide it. they need our services less.

SWOT ANALYSIS
• Strength
• Weaknesses
• Opportunities
• Threats

Fig. 4: SWOT
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Inventory Control

INVENTORY CONTROL
• Stocks usage & Maintenance so as to able to meet demands without any delay, avoid wastage d/t improper
storage or expiry while keeping costs of holding stocks to a MINIMUM.

ABC ANALYSIS

Always

Better

Control

→ (A) (B) (C) → ORS, PCM

Budget 70% 20% 10%
10%
No. of Items 20% 70%

VED Analysis
Vital Drugs/ Items
Essential Drugs/ Items
Desirable Drugs/ Items
V E D
No. of items 10% 40% 50%
Absence be tolerated Can’t be Some time Long time

SDE Analysis HML Analysis

Scarcely available High cost
Difficulty available Medium cost
Easily available Low cost

SOS Analysis
Seasonal
Off-seasonal
FSN Analysis
Fast moving → ORS, PCM EOQ Analysis
Slow moving → Doxycycline Economic Order Quantity
Non moving → Adrenaline
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GOLF ANALYSIS XYZ Analysis

Govt controlled Supplies X High investment
O pen market supplies Y Moderate investment
Local supplies Z Low investment
Foreign market supplies

POWERS OF A MANAGER

POSITIONAL POWERS PERSONAL POWERS

REWARD EXPERTISE
COERCIVE REFFERENT
LEGAL
CONTRACTUAL
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HEALTH CARE IN INDIA

Primary Health Care

PRIMARY HEALTH CARE

According to ALMA ATA 1978
Essential health care characterized by ‘4A,s’
A → Acceptability
A → Accessibility
A → Availability
A → Affordability

Fig. 1: Health care levels

ELEMENTS OF PH CARE [Mnemonic: ELEMENTS]

E → Essential Drugs
– Most essential drug → Paracetamol
– 33-38 Essential Drugs included in PHC
L → Locally Endemic Disease prevention & control
E → Education [Health]
M → Maternal & Child Health [Includes FP]
E → EPI 1978 →UIP 1985 [Universal Immunization Programme]
N →Nutrition
T → Treatment of common ailments
S → Safe water supply & Sanitation
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4 PILLARS/PRINCIPLES OF PH CARE
1. Equitable Distribution
– Social
– Demographic
– Economic
2. Appropriate Technology
– ORS
– Stand Pipes
– Exclusive Breast feeding,
– KMC [Kangaroo Mother Care]
– ↑ RR [Pneumonia diagnosis]
3. Community Participation
– ASHA
– Bare foot doctors
4. Intersectoral co-ordination

CONCURRENT LIST. MOHFW

VITAL Statistics
COMMUNICABLE diseases prevention
Labour welfare
Adulteration of food prevention
PORTS (other than major)
Population Control & FP
Economic & social planning
DRUGS & poison Control
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Levels, Centres, Workers, Norms

LEVELS OF PH CARE
• Tertiary → Second Referral Level /Unit [SRU]
• Secondary → First Referral level/unit [FRU]
• Primary → First contact level b/w population
& health system of country

HEALTH Norms Hilly/ Infrastructure

Population Plains Beds Staff
CENTRES Tribal /DTA Numbers
Tertiary
Medical
Colleges & (-) (-) (-) 500 + (-)
Hospitals
Secondary
CHC 1/120000 1/80,000 30 5,500+ 46-52
Primary
PHC Sub-
Centers 1/30,000 1/20,000 4-6 25,000+ 13-21
(Central Govt 1/5000 1/3000 02 1,55,000+ 3-4
assisted)

SUB CENTERS Type A Type B

Delivery NA Available
HW [m] 1 1
HW [F] / ANM 1 2
Safai Karamchari 1 1
3 4

* MPW = HW

HEALTH CENRES
SUB-CENTRES
IPHS 2022 GUIDELINES
1/5000 plain
HWC – SHC RURAL
1/3000 hilly, tribal
UHWC – URBAN – 1/15,000-20,000
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PHC Type A Type B

No. of deliveries/month < 20 > 20
MBBS Doctor 1 2
AYUSH Doctor 1 1
13-18 14-21

* Health assistant present at PHC (1 M, 1 F)

HEALTH CENTRES PHC-PRIMARY HEALTH CENTRE

– FIRST contact b/w population & Medical care
– 1 PHC → 6 SUBCENTRE
SUBCENTRE PHC, CHC
Central Govt State Government

FUNCTIONS OF PHC
Medical Care Lab services
MCH incl. FP Training Programme
Locally endemic disease P & C
SAFE WS & S
VITAL statistics
Education (Health)
NHP’s
Referral services

PHC – PRIMARY HEALTH CENTRE

IPHS 2022 HWC-PHC GUIDELINES

PLAINS HILLY/TRIBAL
RURAL PHC 1/30,000 1/20,000
URBAN PHC 1/50,000 -
POLYCLINIC 1/2,50,000-3,00,000 -

CHC
→ MD/MS Medical Officers
4 + 3 + 2 → Total 9

1. Medicine - Ophthalmologist 1. Dental Surgeon

2. Surgery - Anesthetist 2. AYUSH Medical Officers
3. GYN & - Public health prog. manager
4. Pediatrics
Total Staff → 46-52
→ Health supervisor present (1M, 1F)
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Levels, Centres, Workers, Norms

CHC – COMMUNITY HEALTH CENTRE

IPHS 2022 CHC Guidelines

PLAINS HILLY/TRIBAL
RURAL CHC 1/1,20,000 30 bedded 1/80,000

METROS NON-METROS
URBAN CHC 1/5,00,000 1/2,50,000
(U-CHC) 100 bedded 50 bedded

GRASS ROOT LEVEL WORKERS

ASHA → Accredited Social Health Activist
MPW → Multi Purpose Worker
VHG → Village Health Guide [community Health worker]
TBA → Traditional Birth Attendant [Trained Dai]
AWW → Anganwadi worker

Location Population Norm Education Training

ASHA Village 2/1000 10th 23 Days

MPW Sub Centre 1/5000 12th 12 months

VHG Village 1/1000 6th 3 months

TBA Village 1/1000 - 1 months

AWW AWC 1/400-800 10th 4 months

ASHA WORKER [Accredited Social Health Activist]

NRHM 2005-12, NHM 2013 –

25 - 45 years old Female Worker

Resident of same village

→ Bridge between → Village & ANM

→ Selected by → Village Panchayat

→ Accountable to → Village Panchayat

→ Training by → ANM & AWW

→ Impact indicators (4 ) → 1. Reduction of IMR [main]

2. TB cases detected

3. Leprosy cases detected

4. PEM rate
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URBAN H. CARE SYSTEM → NUHM 2013

Tertiary
Med colleges -
Hospitals

Secondary
Non-metros 1/2,50,000
U-CHC
Metros 1/5,00,000

Primary
Urban -PHC [U-PHC] 1/50,000
USHA [Urban Social Health Activist] → 1/1000-2500
U-ANM 1/10,000

No Sub center

POPULATION

NORMS Plain Hilly 1ASHA 2/1,000

1 Sub Centre 1/5,000 1/3,000 1MPW 1/5,000
1 PHC 1/30,000 1/20,000 1 VHG 1/1,000
1 CHC 1/1,20,000 1/80,000 1 TBA 1/1,000
1 AWC 1/400-800 1/300-800 1 AWW
1 UHC [U-PHC] 1/50,000 Plains 1/400-800
1 U-CHC Hilly 1/300-800
→ Non-Metros 1/2,50,000
→ Metros 1/5,00,000

Fig. 1: Doctor – Population Ratio

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Levels, Centres, Workers, Norms

1 USHA 1/1000-2500

1 U-ANM 1/10,000

1 Pharmacist 1/10,000

1 LAB Technician 1/10,000

1 HealthAssistant 1/30,000 (1/20,000 in hilly)

1 Health Supervisor 1/120,000 (1/80,000 in hilly)

1 Doctor/1000 population

3 Nurses / 1 Doctor

1 ophthalmologist/ 5,00,000 population / 5 CHC’s

1 TB Microscopy /100,000

1 TB Unit /500,000 (200,000 In NTEP

1 STLS [Sr. Tb lab supervisor] /500,000

1 Malaria Microscopy /25000

1 SET Centre [Survey Education, Rx] /25000

1 ULC [Urban leprosy center] /50000

1 LCU [Leprosy control Unit] /450,00

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PRIs, AYUSH & Socialised Medicine

PRI - PANCHAYATI RAJ INSTITUTIONS

3 TIER | Local Rural Self Government

DISTRICT ZILA PARISHAD

BLOCK PANCHAYAT SAMITI
VILLAGE PANCHAYAT~ GRAM Sabha, GRAM Panchayat, NYAYA Panchayat
Administrative powers by
73rd & 74th Amendments in Constitution

ALTERNATIVE FORMS OF MEDICINE

• Earlier Name → ISM & H [Indigenous system of Medicine & Homeopathy]

→ Newer Name → AYUSH

Ayurveda

Indian Origin

Yoga & Naturopathy

Unani → Greek Origin

Siddha → Indian Origin

Homeopathy → Germany
• [Father → Samuel Hahnemann]

SOWA-RIGPA
Chinese, Taiwan System of faith Healing
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Fig. 1: AYUSH

STATE MEDICINE
– Free Medical care by govt. of a country

SOCIALIZED MEDICINE
– Free medical care by Govt. but regulated by professional groups/bodies
– Started in RUSSIA 1978

Advantages of Socialized Medicine

1. Prevent competition among Private Practitioners
2. Provision of Medical Services by state Govt.
3. Social Equity
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INTERNATIONAL HEALTH
International Health Agencies

WHO [World Health Organisation]

• Established 1945
• Constitution came into force on 7th APRIL 1948
• 7th APRIL - WORLD HEALTH DAY
• Headquarter located in GENEVA [Switzerland]

Fig. 1: Health For All (WHD theme 2023)

• Composition of WHO

Fig. 2: WHO Logo

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World Health Assembly

WHO Executive Board

SEcretariate

Fig. 3: WHO components

UNICEF [United Nations International Children Emergency Fund/ UN Children

Fund]
• Head quarters → New York
• GOBI - FFF campaign
G – Growth Monitoring F - Family Planning
O – ORS F - Female Education
B – Breast Feeding F - Food Supplementation
I – Immunization

ILO [International Labour Organization] Fig. 4: UNICEF Logo

• HQ → Geneva

Fig. 5: ILO

FAO [Food & Agricultural Organization]

• HQ →
Rome, Italy → FFHC [Freedom from Hunger campaign]

Fig. 6: FAO

IRC [International Red cross]

• HQ → Geneva → Henry DUNANT
Poverty, Climate Change & Food Security

WORLD BANK - 1944

Headquarters – Washington D.C.
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International Health International Health Agencies

UNDP [United Nations Development Programme] – 1966

Headquarters – New York

UNFPA [United Nations Fund for Population Activities]

Support in Family Planning Prog. of India (Under RCH)

Fig. 7: UNDP

Fig. 8: UNFPA

UNESCO [United Nations Educational, Scientific and Cultural Organization]

Headquarters - Paris

Fig. 9: UNESCO

SIDA [Swedish International Development Cooperation Agency]

Support in NTP Program

Fig. 10: SIDA

DANIDA [Danish International Development Agency]

Start and Support in Blindness Program

Fig. 11: DANIDA

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SDG, Bioterrorism, Biosafety

INTRODUCTION – MDGs
MDGs 2000-2015
3/8 Goals – directly Health related 4, 5, 6

Fig. 1:
In 2015, UN launched a fresh set of goals
• SDG – Sustainable Development Goals
• 2015 – 2030
• 17 Goals – 1/7 Goals – directly Health related – GOAL NO. 3

United Nations in 2015 (sDG)

• 170 countries
• It is a part of UN Resolution 70/1 (2030 Agenda)
1. To End Poverty
2. To Protect Planet By 2030
3. Peace/Prosperity (for all of humanity)

1. No Poverty
2. Zero Hunger
3. Good Health &Well – being
4. Quality Education
5. Gender Equality
6. Clean Water & Sanitation
7. Affordable& Clean Energy
8. Decent work & Economic growth
9. Industry, Innovations and Infrastructure
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10. Reducing Inequality

11. Sustainable Cities & Communities
12. Responsible Consumption & Production
13. Climate Action
14. Life Below Water
15. Life on Land
16. Peace, Justice & Strong Institutions
17. Partnerships for the Goals

Fig. 2: 17 Goals, 169 Targets, 232 Indicators

sDGs – Targets & Indicators

3.1 - By 2030, MMR < 70
3.2 - By 2030, NNMR 12 & U5MR 25
3.3 - By 2030, end epidemics of AIDS, TB, Malaria and NTDs and combat Hepatitis, Water – borne diseases
and other CDS.
3.4 - By 2030, reduce by 1/3 premature mortality from NCDs.
3.5 - Strengthen the prevention & treatment of substance abuse.
3.6 - By 2020, halve the global deaths and injuries form RTA.
3.7 - By 2030, universal access to Sexual & Rep – health care services.
3.8 - Achieve Universal health coverage.
3.9 - By 2030, reduce the number of deaths, illnesses form hazardous chemicals and air, water and soil
pollution and contamination.

BIOTERRORIsM AGENTs

CATEGORY A CATEGORY B CATEGORY C

→ Most Dangerous → Less dangerous - New

→ Most easy to spread → Less easy to spread - Emerging

→ 1. Anthrax [MCused] → 1. Brucellosis 1. HANTA Virus

2. Small Pox [most dangerous] 2. Melidiosis 2. NIPAH Virus

3. Plague 3. Psittacosis

4. Botulism [most lethal Toxin] 4. Glanders

5. Tularemia 5. Staph Toxin

6. Viral Haem. Fevers 6. Ricin Toxin

7. Q fever
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SDG, Bioterrorism, Biosafety

8. Epidemic Typhus

9. Food Safety Threats

10. WaterSafety Threats

11. Clostridium Per fringes

• Acc to IHR’s, Air travel in pregnancy is permitted up to 36 wks POG in Singleton Pregnancy.
• Air travel in pregnancy is permitted up to 32 Wks POG in TWIN Pregnancy.
• After 28 Wks, should carry EDD Certificate [Expected Date Of Delivery Certificate]

BIOsAfETy LEvELs

Fig. 3: Biosafety Levels

Bio safety Levels (BsL)

AKA pathogen Protection Levels, Bio Containment Levels.

Fig. 4 : Biosafety Levels

• Set of Bio-containment precautions that are required to isolate dangerous biological agents in
4

BSL 3

1
• They progressively move from 1 to 4 in order of increasing risk from that particular microbe (or) organism
• When we look at these four bio safety levels they are represented by individual symbol at biohazard (or)
bio medical waste
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BsL – 1
• It is meant for basic teaching & research type of Labs
• Here the focus is on “Good Microbiological Technique” (GMT)
• According to CDC Atlanta Guidelines these include
– Nonpathogenic strains of E.coli
– Nonpathogenic strains of staphylococcus
– Bacillus Subtilis
– Saccromycis Cerevisiae
Also other organism which don’t contribute to Human disease. Fig. 5:

BsL – 2
• Primary Health services, Diagnostic, Research Laboratories
Good Micro biological Technique + use of protective clothing + Bio hazard symbol
Organism under BSL – 2 include
• Hepatitis A, B, C
• HIV
• Pathogenic strains of E-coli
• Pathogenic strains of staphylococcus
• Salmonella
• Plasmodium Falciparum
Fig. 6:
• Toxoplasma Gondii

BsL – 3
• It is meant for special type of diagnostic services of research labs.
Evel 2 + Special clothing + Controlled Access + Directional Airflow
• BSL – 3 organisms include:
– Franciscella Tuberoses
– Mycobacterium Tuberculosis
– Chlamydia Psittaci
– Venezuelan Equine Encephalitis Virus (VEEV)
• Easter Equine Encephalitis Virus (EEEV)
– SARS – COV 1, COV 2, MERS Fig. 7:
– Rickettsia
– Coxiella Brunetti
– Rift valley fever virus
– Brucella
– Chicken Guinea fever virus
– Yellow fever virus
– Western Nile Virus
– Yersinia Pestis

BsL – 4
• Dangerous Pathogen Units/ Labs
Level 3 + Airlock entry + water shower exit + special waste disposal
Organism in BSL -4 include
Fig. 8:
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SDG, Bioterrorism, Biosafety

– Ebolavirus
– Marburg Virus
– Lassa virus
– Hendra virus
– Nipa virus
– Flavivirus

Biosafety Levels of COvID:

• BSL has become a quite important due to emergence of coronavirus across the planet as a biggest pandemic
ever in recent years
• If you look at the biosafety levels in relation to covid 19 (or) SARS-COV -2 it involves two different
biosafety levels.

BsL – 2 BsL – 3 (single best answer)

Routine Diagnostic Testing of specimens’ Viral isolation in cell culture & Initial characterization
of the isolated viral agents.
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Diseases Covered Under International Health

Regulations WHO

A. notifiAble diseAse
1. immediately notifiable diseases [< 24 Hrs]
(Mnemonic Piss)
→ Small pox → Human Influenza
→ Wild Polio → SARS

2. Potentially notifiable disease

a. Public Health importance
• Cholera
• Plague
• Yellow fever
• Viral Hemorrhagic Fevers [Ebola, Marburg, Lassa]
• West Nile Fever
• Dengue
• Rift valley Fever
• Meningococcal Disease

b. biological/Chemical/Radiological events
c. serious illness of Unknown origin

b. diseAses UndeR tRAining & ReseARCH

1. Malaria 7. Onchocerciasis
2. Filariasis 8. TB
3. Leprosy 9. VBD [Dengue, CGF, Zika]
4. Leishmaniasis 10. Ebola
5. Trypanosomiasis 11. Helminthiasis
6. Schistosomiasis

C. list of QUARAntinAble diseAses

1. Diphtheria 6. SARS
2. Infectious Tuberculosis 7. Viral Haemorrhagic Fevers
3. Plaque 8. Cholera
4. Small Pox 9. FLU (Pandemic)
5. Yellow Fever
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HISTORY OF MEDICINE
History

PRIMITIVE MEDICINE
1. AYURVEDA [AYUR – LIFE, VEDA-SCIENCE]
GOD of ayurveda – DHANVANTARI
TRIDOSHA theory of disease
VATA - wind
PITTA - gall
KAPHA – mucus

2. HOMEOPATHY Louis Pasteur

Father of homeopathy – SAMUEL HAHNEMAN

First principle – SIMILIA SIMILIBUS CURENTER
Second principle – single drug use
Third principles – minimum dose

3. SIDDHA SYSTEM
Tamil speaking state
Treatment is based on
Environment
Age, sex, race Edward Jenner
Physiological constant

4. UNANI SYSTEM
Origin – Greek origin

HUMORAL THEORY PATIENT’S CHARACTER

Blood Sanguine
Phlegm Phlegmatic
Yellow bile Choleric
Aristotle
Black bile Melancholic

5. CHINESE SYSTEM
World’s 1st organized system of medical knowledge
Rice farmers – BAREFOOT DOCTORS
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DISCOVERIES AND INVENTIONS

• First vaccine & term medicine – EDWARD JENNER (small pox)
[FATHER OF IMMUNOLOGY]

LOUIS PASTEUR
• Term vaccine
• Father of microbiology
• Germ theory
• Vaccines – rabies, anthrax, chicken cholera

• First polio vaccine – JONAS SALK

• First antibiotic (penicillin) – ALEXANDER FLEMING
Hippocrates
• Citrus fruit prevent scurvy – JAMES LIND
• Antiseptic – JOSEPH LISTER
• Transmission of yellow fever – WALTER REED
• Life cycle of plasmodium – RONALD ROSS
• Blood groups – KARL LANDSTEINER
• Growth chart – DAVID MORLEY
• Canon of medicine & the book on healing – AVICENNA
• Antiseptic – JOSEPH LISTER

HIPPOCRATES
• Book on air, water & place – HIPPOCRATES
• Charaka Samhita – CHARAKA
• Sushruta Samhita – SUSHRUTA

REVOLUTION IN MEDICINE
Charaka
1. STATE MEDICINE Free Medical care by GOVT.
2. SOCIALISED MEDICINE
• Regulated by professional groups
• Russia

FIRST COUNTRY TO COUNTRY

START FAMILY PLANNING PROGRAM INDIA
START BLINDNESS CONTROL PROGRAM INDIA
START FINGER PRINTING INDIA
SOCIALISED MEDICINE RUSSIA
COMPULSORY SICKNESS INSURANCE GERMANY

Sushruta
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BIOSTATISTICS
Variables & Scales

BIOSTATISTICS
Application of statistics in BIOLOGY, MEDICINE & PUBLIC HEALTH
DESCRIPTIVE – organise, represent & describe collected data – GRAPHS & TABLES
INFERENTIAL – describe meaning of collected data
APPLIED - deal with real world problems & offer solutions

VARIABLES
Anything which can have a different value.

CLASSIFICATIONS
QUANTITATIVE QUALITATIVE
Can be measured & can be compared Can’t be measured & can’t be compared
Weight, Height, Hb, B. sugar, S. Cholesterol, Pain, ABO grouping, Rh system, Diabetes, Ane-
Pulse Rate, SBP, BMI, C/°F, Age, Mid arm cir- mia, Sex, Religion
cumference, Parity, Income
CONTINUOUS DISCRETE
Many possible values & in between values Few possible values & No in-between values
Weight, Height, Hb, B. Sugar, SBP, C/°F, Age, ABO grouping, Rh status, Sex, Parity, Religion,
Mid arm circumference, BMI, Pulse rate Anemia, Types of Anemia, Severity of Anemia
DICHOTOMOUS POLYOTOMOUS
Only 2 possible values > 2 possible values
Rh status, Blood group B Weight, Height, Hb, B. sugar, S. cholesterol,
Obesity, Anemia BMI Pulse Rate, SBP, ABO grouping, Sex, type
of Anemia, TNM staging, Age, Religion, Parity,
C/°F
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SCALES OF MEASURMENT
Categorical Dimensional
NOMINAL ORDINAL METRIC
Names Order Measurement
ABO, Rh, Anemia, TNM staging of Cancer Weight, Height, Hb, B.
Types of Anemia Severity of Anemia sugar, PR, SBP, BMI, S. choles-
HTN Classification terol, Age, °C/°F, Parity

Sex
• Most of Qualitative Scales, measured on Categorical Scale and Most of Quantitative Scales, measured on
Metric Scale
• Statically most preferable scale → METRIC >Ordinal > Nominal

Metric Scale
Interval Ratio
NO Ratios are possible, Ratios ARE possible, HAVE
HAVE no ABSOLUTE zero ABSOLUTE zero PRESENT
°C/°F Temp Weight, Height, Hb, B.SUGAR, S. cholesterol, Age, BMI, Pulse
RATE, SBP, Kelvin Temperatures

• Majority of metric variable should be measured on Ratio scale except °C/°

Likert Scale

Fig. 1: Likert scale

• Type of ordinal scale
• Based on continuum of Response

Guttman Scale
• Statements of increasing intensity
• Type of ordinal scale
• based on continuum of Response

Adjective Scale
• Grammatical words of increasing intensity
• Hot-warm-Lukewarm, chill-cool-pleasant
• Type of ordinary scale, based on continuum of response
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Biostatistics Variables & Scales

Likert Scale Guttmann Scale Adjective Scale

• Words • Complete sentences • Words

• Bidirectional • Unidirectional • Unidirectional

VISUAL ANALOG SCALE [VAS]

→ used for measurement of Pain

Fig. 2: VAS

Smileys scale is
• used when pt. is illiterate, ICU, under anesthesia, pediatric pts.
• But preferred is number scale

Fig. 3: VAS
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Central Tendency

MEASURES OF CENTRAL TENDENCY

Sum of all the observations Sum
Mean =
No. of observations n
= Statistical Average
Median: Middle value in ascending order [n = odd] or
Average of 2 middle values in Ascending order [n = even] Mode → Most frequent value

Q Marks scored by 9 students student Q Marks scored by 10

9,1,3,3,0,4,8,7,6, 9,1,3,3,0,4,8,7,6,9
41 50
Mean → → (4.5) Mean → → (5)
9 10
4+6
Median = 0,1,3,34,6,7,8,9 (4) Median = 0, 1, 3, 3, 4,6, 7, 8, 9, 9 2
=5

Mode → 3 Mode → 3 & 9 Bimodal Distribution

3+9
= 6 → Unimodal Distribution
2
MEDIAN
- n = ODD n = EVEN
th th
th
n n 
 n + 1  2  +  + 1
 2  value 2 
2

• Mean > Median > Mode

Statistically most preferable measure of central tendency → Mean
• Best measure of central tendency, if Data is
– Nominal → Mode
– Ordinal → Median
– Metric → Mean
– Skewed metric data → Median
• OUTLIERS
• Tests used for identification of Outliers
DIXON’S Q Test
GRUBB’S Test [used for normal distributed data]
CHAUVENET’S CRITERION
PIERCE CRITERION
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PSM

Q Mean Hb → 12
Median → 13
Mode Hb → ?
→ Mode = 3 Median - 2 Mean
(only applicable for Bimodal Distribution)
→ Mode → 3 (13) -2(12) = 15
Qn = 20 student
One student with highest weight [58Kg] was recorded 85 Kg
Mean → increases
Median → SAME
Mode → SAME
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Dispersion, SD

• Spread Of or Scattering Of Values around a Central Value In a Data Distribution

• Measured by

Individual Observations Samples

Range Standard Error
Interquartile Range SE of Mean
Mean deviation SE of difference b/w two means
standard deviation [mc used] SE of Proportion
Co-efficient of variation SE of difference b/w 2 proportions
Variance

1. STANDARD DEVIATION [σ]

• Deviation of each value from the standard value [Mean]

→n = 100
Mean wt = 60 Kg
D D2

W1 = 64 kg +4 16 RMSD [ROOT of
W2 = 56 kg -4 Total SD = 0 16 Mean of Squares of

W3 = 54 kg -6 [limitations] 36 Deviation

W4 = 60 kg 0 0 ↓

Standard deviation

W100
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2. STANDARD ERROR
• Deviation of each sample mean from the population mean
• Sample mean is known as Statistic, Population mean is known as Parameter

Q n = 100
Wt follow N distribution Mean wt=50 Kg
SD of Wt = 1 Kg SE Mean=?
SD Ã
SE = =
Mean n n

1kg
= = 0.1kg
100
Q. Weight follows N Distributions
n1= 100 Kg n2= 200
M2= 50Kg M2= 60 kg
SD1 = 1 Kg Sd2 = 3 Kg

SE of Difference b/w 2 sample means = ?

s 21 s 22
→ SE of Difference b/w 2 sample means = +
n1 n 2
12 32 →
1 9
→ + +
100 200 100 200

Q Weight follow N distribution

n= 100
Mwt= 50 Kg
40% = Obese
SE =?

pq
– SE of Proportion -
nr
0.4 x́ 0.6
→
100

P = given proportion
q = 1-p

Q. Wt follows N Distribution
n1 = 100 n2 = 200
M1 = 50 Kg M2 = 60
40% Obese 30% Obese

p q p q
1 1+ 2 2
→ SE of difference b/w two proportions → n n
1 2

→ SE does not depends on Mean

x 0.6 0.3 x´ 0.7
0.4 ´
+
100 200
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Dispersion, SD

3. VARIATION /VARIABILITY
Co-efficient of Variation [COV] = SD/Mean x 100

Q. Weight follows N Distributions

n1 = 100 n2 = 200
M1 = 50 M2 = 60 kg Which sample has more variation?
Sd1 = 1 Kg Sd2 = 3 Kg
Which sample is more variation
– COV1 1/50 *100 =2% COV2 = 3/60*100 =5%
– 2nd sample has more variation than 1st sample

4. VARIANCE
V = σ2
V1 = 12 V2 = 32 V2 > V1

5. PRECISION
1 n 100 10 200
P= = p1 = = p2 = = 4.5 P1 > P2
SE s 1 1 3
6. RANGE
Max value - Minimum value OR Expressed as Minimum to maximum
→ E.g.: min → 40 Kg
Max → 100 Kg
Range → 60 Kg or
40-100 Kg

7. RELATIVE DEVIATE [Z SCORE]

Q. n = 100
Hb shows N Distribution
Mean Hb = 13.5 g/dl
SD Hb = 1.5 g/dl
Z score of a student whose Hb is 15 g/dl ?
→ Z Score = (X- Mean)/SD

x = given value
µ = mean value
L
15.0. - 13.5g / DI
=1
1.5g / DL

(Z score can be negative, Zero also)

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Normal Distribution & Skewed Distribution

NORMAL/GAUSSIAN/STANDARD DISTRIBUTION

Fig .1: NORMAL DISTRIBUTION

1. B/L Symmetrical Bell shaped curve
2. Mean = Median = Mode → Known as coincidence
3. If Mean = 0 in Normal Distribution then SD is 1
4. Mean ± 1SD Covers 68% value [68.3%]
5. Mean ± 2SD Covers 95% value [95.4%]
6. Mean ± 3SD Covers 99% value [99.7%]

Fig .2: NORMAL DISTRIBUTION

Q1. WND
n = 100
Mean wt = 60 Kg
SDW = 5 Kg
Q2. 95% student weight lie b/w 50 Kg to 70 Kg → M ± 2SD = 95%
60 ± 2[5] = 95%
60 ± 10 = 95%
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Q3. 68% Students weight lies b/w 55 Kg to 65 Kg

→ M ± 1SD = 68%
60 ± 5 = 68%
Q4. 99% students weight lies b/w 45 Kg to 75 Kg
→ M ± 3 SD = 99%
60 ± 3(5) = 99%
60 ± 15 = 99%
Q5. How many students will have wt> 60 Kg → 50%
Q6. Infinity [None] SD covers all 100% values in a ND → M ± 1SD = 68%
M ± 2SD = 95% M ± 3SD = 99.7%
– Graph never touches base line → Floating graph

POINT OF INFLECTION

Fig .3: POINTS OF INFLECTION

Point of Inflection
• Where top convex become concave on side
• Location of Point of infection on X-axis is about 1 SD
• Area covered by the points of Infection is 68%

Skewed Distributions

Fig .4 : SKEWED DISTRIBUTIONS

• Longer tail going towards Rt/+ve side = RIGHT SKEW
• Longer tail going towards Lt/-ve side = LEFT SKEW
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Normal Distribution & Skewed Distribution

Direction Of Longer Tail Decides The Direction

• Rt/+ve Skewed • Lt/-ve Skewed
Clustering of Values on Lower Side - Right Clustering of Values on Higher Side Left
Skewed Curve Skewed Curve
• Mean > Median > Mode • Mode > Median > Mean

POISSON’S DISTRIBUTION
• No. of events are expressed in unit time
• No. of OPD patients/Day

BINOMIAL DISTRIBUTION
DISCRETE PROB. DISTRIBUTION where each values takes either of the two options
Example… H H T H H H T T

UNIFORM DISTRIBUTION
CONTINUOUS PROB. DISTRIBUTION whwre all values have equally probable
• CONTINUOUS
• DISCRETE
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Statistical Errors, P-Value, Confidence Intervals

STATISTICAL ERRORS
Null Hypothesis H0
– Statement opposite to hypothesis
– E.g. New Drug ‘A’ vs older Drug ‘B’
Null hypothesis-New Drug is NOT BETTER than older drug B

Reality

Ho True Ho FALSE
Reject Ho Type I Error No Error
Accept Ho No Error Type II Error

Based on Study Results (Reject or Accept null hypothesis)

• Ho True, rejected → Type I Error,
• Ho False, Accepted → Type II Error,
• Ho True, Accepted → No Error,
• Ho False, Rejected → No Error
• Type I Error is more severe than type II Error
• P Value → Probability of Type I Error
• α → Max. Threshold [permissible] of type I Error
• Globally accepted value of α → 5%
• β → Probability of Type II Error
Q. Which is True? Q. Which you want in your study
(a) P < α (a) p < α
(b) P = α (b) p = α
(c) P > α (c) p > α
(d) Any of above (d) Any of above
→ If P <α → Results are significant
P value should be < 5% [0.05]
Q In cohort study I, RR=8, in smoking to cancer, cohort study
P value = 0.07 conclusion → Insignificant Results
Q CSII, RR=6, P value = 0.04 → Significant Results
Q CS III, RR=5.2, P value = 0.02 → MORE Significant Results
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CONFIDENCE LEVEL [1 - α]
• Probability that value of a parameter falls with in a specific range.
• Confidence level can be ↑ed by ↓ingα.
• for significant result → 1-0.05 = 0.95 → 95% minimum CL

Q CS I, RR = 8, [CL = 93%] → Insignificant

Q CSII, RR = 6, [CL =96%] → Significant,
Q CSIII, RR = 5.2, [CL=99%] → More significant

POWER OF A STUDY [1-β]

• Power of study ↑ ed by ↓ing β
• Probability that a test will reject a false Null Hypothesis

MCQ Probability of declaring a significant difference in a study when actually it is not present

Reality
→ Ho → there is no significant difference

– In Reality → True

– Investigator → Rejected TYPE 1 ERROR

CONFIDENCE INTERVAL
• Interval that may contain a population parameter calculated
• Gives estimated range of values
• E.g.

CHI, RR = 8 [CI → 7.6 - 8.4]

→ Formula

CI = Mean ± Z [SE] Z 90%→ 1.645

CI = Mean ± Z [SD/√n] Z95% → 1.96

MCQ
n = 100
Mean GFR = 85 ml/min

SD = 25ml/min

Range of 90% CI?

→ CI90 = 85 ± 1.645 [SD/√n]
= 85 ± 1.645 x 2.5

= 81 – 89

Larger the sample Size, narrower the CI

Narrower CI is preferable as it tells more precisely that what might be the pop. Mean
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Statistical Tests

PARAMETRIC TEST OF SIGNIFICANE NON -PARAMETRIC TESTS OF SIGNIFICANE

• Normal Distributions • Non normal Distributions

• Quantitative • Qualitative

• Means, SD compared • % Fractions compared

• Paired student’s t test Unpaired student’s • SIGN Test

t test ANOVA [F-Test] • CHI SQUARE TEST

PARAMETRIC TESTS → used to COMPARE MEANS, SD in

1. PAIRED STUDENT’S t TEST → Paired Data [1 Groups]
2. UNPAIRED STUDENT’S T TEST → unpaired Data [2 Groups]
3. ANOVA [F-Test] → Unpaired Data [> 3 Groups]

NON PARAMETRIC TESTS → Used to compare % fraction in

1. SIGN TEST Paired Data [1 Group]
2. CHI SQUARE TEST Unpaired Data [> 2 Groups]

→Sign test analogous to Paired student t test

Unpaired students t test
→Chi-square test analogous
ANOVA [F-Test]

Q) n = 10 Q) n = 10
Mean SBP = 142 mm Hg Mean SBP males = 142 mm Hg
Drug H x 2 months Mean SBP females = 126 mm Hg
Mean SBP = 126 mm Hg

Paired Students t test Unpaired students t test

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Q) n = 10 Q) n = 100
MSBP Ward 1 = 142 mm Hg 40 % HTN

MSBP Ward 2 = 126 mm Hg Drug H x 2 months

MSBP ward 3 = 140 mm Hg 26% HTN later

ANOVA [F-Test] SIGN TEST

Q) n = 100 Q) n = 100
40 % Males HTN Ward 1 40% HTN
26% females HTN Ward 2 26% HTN
Ward 3 22% HTN

CHI Square Test CHI- Square Test

Z - Test
• Variation of t test
• used only if n is > 30

Fischer’s exact test

• Variation of chi-square test
• used only if n is < 30

CHI-SQUARE TEST

Chi-Square Test
• Test of association b/w ≥ 2 QUALITATIVE CHARAC.
• NON-PARAMETRIC (NON-Normal Dist.)

Applications
• Test of association
• Test of Proportions
• Test of Goodness of fit

Requirements
• Random sample
• Qualitative data
• Each cells ≥ 5 OR YATE’S CORRECTION Should be used

• Degrees of freedom [DOF]

DOF = [C-1] [r-1] → more Accurate
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Statistical Tests

Q) 3x4 table, DOF = 2x3 = 6

2x2 table, DOF = 1x1 = 1
3x5 table, DOF = 2x4 = 8
4x4 table, DOF = 3x3 = 9
DOF = n-1

Q) n = 100 , DOF = 99
DOF = (n1+n2)-1

Q) n1 = 60, n2 = 40; DOF = 99

→ value of Chi-square 3.84 for 2x2 table [DOF =1] at 95% CL?

OTHER STATISTICAl TESTS

Wilcoxan Tests
1. Wilcoxan SIGNED Rank Test - Compare % Fractions in MATCHED PAIRED Data.
2. Wilcoxan Rank Sum Test - Compares% Fractions in Two Unpaired samples
3. MANN WHITNEY (WIlCOXAN) TEST - Test if Two set of observations have come from
same pop. (2 independent non-paired samples)
Kolmogorov-Smirnov Test
• Non-parametric test to compare 2 samples
• If 2 data sets differ significantly
Bland Altmann Analysis
• Assess level of Agreement b/w 2 methods
• Compare NEW technique VS OLD technique
Cronbach’s AlPHA
• Measure Intrenal Cosistency/Reliability
• Used in LIKERT SCALE
• Value 0 to +1
• ≥ 0.7 satisfactory
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Statistical Graphs, Correlation, Regression &

Locations

STATISTICAL GRAPHS

QUANTITATIVE QUALITATIVE
Histogram Bar chart
Frequency Polygon Pie chart
Frequency curve Map
Line chart Pictogram
OGIVE
Scatter Diagram
[F2LOSH: MNEMONIC]

Fig. 1: BAR CHARTS

Fig. 2B: Histogram Fig. 2B: HISTOGRAM Fig. 3: Bar Chart

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Fig. 4: Frequency Polygon Fig. 5: Frequency curve

• Frequency polygon = By joining the top middle points ofeach bar in a histogram by a straight Line
• Frequency curve = By joining the top middle point of each bar in a histogram by a curve line
1. ↑ing the sample size
2 reducing the interval size on x-axis

Line Diagram
• Depiction of TREND
• Different from Frequency polygon

Fig. 6: Line Diagram

1. No closed loop
2. No Histogram in the background

OGIVE/cumulative Frequency Diagrams

• Frequency only increasing
• No closed loop
• No Histogram on background

Fig. 7: OGIVE
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Statistical Graphs, Correlation, Regression & Locations

Fig. 8: DOT/Scatter Diagram

Fig. 9: Bar Chart Fig. 10: Pie Chart/Sector Chart

Fig. 11: Map Fig. 12: Pictogram

PIE CHART/SECTOR CHART

1. Total of all categories in the data must be 100% and
2. All categories must be mutually exclusive

Fig. 13: PIE CHAT

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SCATTER/DOT DIAGRAM
• Used for depiction of correlation [Relationship b/w 2 Quantitative variables]
1. POSITIVE CORRELATION
• 0 < r < +1
• E. g. H &W = + 0.8
• Ht &wt are in Positive correlation

Fig. 14: POSITIVE CORRELATION

2. Negative Correlation
-1 < r < o
• Vitamin A is protective for epithelial cancer
• Condom use & HIV Transmission → 0.9

Fig. 15: NEGATIVE CORRELATION

• Condom use & HIV transmission are in negative correlation
• for 1 unit increase of condom use, there is 0.9 unit decrease in HIV transmission
• Condom usage is protective against HIV transmission

3. No/ABSENT CORRELATION
• r=0

Fig. 16: ABSENT CORRELATION

• In a study correlation co-efficient lies between – 1 < r < +1
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Statistical Graphs, Correlation, Regression & Locations

Coefficient of Determination
• % Change in one variable that can be explained by change in another variable
• COD = r²
Q. r Ht & wt = + 0.7
COD = ?
→ COD = [+0.7]2
= 0.49
= 49%
Interpretation → 49% ↑ in wt can be explained by ↑ in Ht, other 51% ↑ in wt can be explained by other variables

Q. r vit A intake & Epithelial cancer = -0.9

COD interpretation → ?
→ COD = (-0.9)2 = +0.81 = 81%
Interpretation →81% ↓ in epithelial cancer can be explained by ↑ in vit. A intake (19% ↓ can be explained
by other protective variables)

REGRESSION
→ Structure of exact relationship b/w 2 variable
→ y = a + bx
y → dependent variable [DV]
x → independent variable [IV] a → constant
b → Regression Coefficient

TyPES OF REGRESSION
y = a + bx SIMPLE LINEAR R
y = bx1 + cx2 MULTIPLE LINEAR R
y = a + bx³ SIMPLE CURVILINER R
y = a +bx1³ + cx72 MULTIPLE CURVILINEAR R

• Simple → only 1 Independent variable

• Multiple → >1 Independent variable
• Linear → Independent variable has no power [=1]
• Curvilinear → At least one independent variables has power >1)

MCQ. Occurrence of a disease is dependent on multiple risk factors. which

type of Regression it will be? = Multiple Logistic Regression
• If dependent variable is
– Polytomous → Multiple curvilinear Regression
– Dichotomous → Multiple Logistic Regression
• Occurrence of a disease → Dependent variable → Dichotomous → MLR
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Sampling & Sample Size

SAMPLING
RANDOM/PROBABILITY/NON-PURPOSIVE NON-RANDOM /NON-PROBABILITY/
SAMPLING PURPOIVE SAMPLING
1. Simple Random 1. Convenience Sampling
2. Systematic Random Sampling 2. Quota sampling
3. Stratified Random Sampling 3. Clinical Trial sampling
4. Multistage Random sampling 4. Snow Ball sampling
5. Multi phase Random sampling
6. Cluster Random Sampling

SIMPLE RANDOM SAMPLING

• Random → Equal & Known chance
• n = 100

Average IQ level → ?
• sample = 10
1. Lottery Method
2. Random Number Tables Booklet [Most Accurate]
3. Software
4. Currency notes

Fig .1: SIMPLE RS

Systematic Random Sampling

• Sampling fraction/sampling interval = Systematic
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Q. n = 100 Sample
= 10 Average IQ level

Fig .2: SYSTEMATIC RS

10
• SF =100 = = every 10th student selected
10
• Random → In the 1st Row, student will be selected by SIMPLE RANDOM Method

Stratified Random Sampling

Q. n = 100 students
= 50 Boys
= 50 Girls
Sample = 10 Avg. Hb level ?

Fig .3 : STRATIFIED RS
• STRATIFICATION- Conversion of heterogenous population to homogenous groups / strata
• Then Random Sampling is done from each group/strata

Multistage Random Sampling

Q. n = 100 villages
→ In India → 36 states & Union Territories
↓
5 states
↓
10 Districts
↓
2 villages
↓
100 villages
→ Sampling done in staging
→ Randomisation should be done in each stage of sampling
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Sampling & Sample Size

Multi Phase Random Sampling

Q. Sample → 100 sputum smear + ive cases selection

→ 5,000 patients/Day OPD

2,000 OPD patients

cough > 2 wks

No

EXCLUDED 1000 Yes

500→ ss -ve SS Ex.

500 SS +ve

100 SS +ve

• Phase → Part of information is obtained in each stage & some are excluded based on that information for
Randomization, either 1st or last stages are used

CLUSTER RANDOM SAMPLING

• Used for Immunization coverage evaluation
Simple RS
Systematic RS Error is about ± 30%
Stratified RS for immunization
Multistage RS Evaluation
Multiphase RS
• CRS Errors Rate for Immunization coverage Evaluation →± 5% →
• WHO Recommended Technique → 30 x 07
30 cluster, 07 Children [12-23 months of age] in each cluster
→ E.g.
30 clusters are selected by systematic Random sampling
↓
Select 1st 7children of each cluster
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PSM

Fig .4: CLUSTRE RS

• Total sample Size → 210 [30x7]

• Intercluster disparity → even the clusters are not comparable to each other
– To remove inter cluster disparity, we use DESIGN EFFECT

Convenience Sampling
Q. Avg. Hb level of all medical students
[5 medical colleges] → ?
Sample Size = 100

Fig .5: CONVENIENCE SAMPLING

• Sampling according to convenience [Availability] of Investigator
• Non Random sampling

Quota Sampling
Q. Avg. Hb level of all medical students [5 medical colleges] → ?
Sample Size = 100
BIG SAMPLE is divided into smaller Quotas & Within each Quota there is convenience sampling
Non Random version of→ STRATIFIED RANDOM SAMPLING

Fig .6 : QUOTA S
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Sampling & Sample Size

Snow Ball Sampling

Used for Hidden population
• commercial sex workers
• Injecting Drug users
• HIV +

CLINICAL TRIAL SAMPLING

• Always done first come first basis.

SAMPLE SIZE ESTIMATION

Q. Prevalence of candida = 50%
What is the minimum sample size required to estimate prevalence of candida at 95% confidence level?
→ Type of cross sectional study formula P = prevalence from older study
for cross sectional study is
SAMPLE Size = 4 Pq /l2 l = permissible error (CL = 95%)
q = l-p l = 5% → 0.05
4 × 0.5 × 0.5
=
(0.05)2
= 400
• Even if P is unknown, by default take it as 50%
• Even if CL is unknown, by default take it as 95%

SAMPLE SIZE
Sample Size Depends On
• EFFECT SIZE
• STANDARD DEVIATION SD ()
• Significance Level ()
• POWER ()

Increase In Sample Size

Decreases
• CONFIDENCE INTERVAL
• SE MEAN
• ALPHA ERROR
Increases
• PRECISION
• POWER of TEST
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Locations, Probability, Miscellaneous

LOCATIONS
Divides Into Equal Parts
Quartiles 4
Pentiles /Quintile 5
Tertiles 3
Percentile/centile 100

Fig. 1: Locations
Qualities and data distrbution
Q1 Q2 Median Q3

25 % data 25% data 25% data 25% data

Lowest Highest

Q1 → 1:3 P1 → 1:4 T1 → 1:2

Q2 → 1:1 P2 → 2:3 T2 → 2:1

Q3 → 3:1 P3 → 3:2

P4 → 4:1

Median → Q2 →1:1 → 50th percentile

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PROBABILITY & ODDS

Probability
• A chance that an event will occur
• O < probability < +1

Rule of Addition Rule of Multiplication

• For mutually exclusive events P[T] = • For independent events and we asked their Joint
P[A] + P[B] probability P [T] = P [A] X P [B]

• BW <2.5 Kg → 0.30 • BW

2.5-2.999 → 0.20 <2.5 Kg →0.30 Male→0.50

≥3 Kg→ 0.50 ≥ 2.5 Kg → 0.70 Female→0.50

1. Probability of a child > 2.5 Kg? 1. Probability of a child BW ≥ 2.5 Kg, Male?
P [T] = 0.20+0.50 = 0.70 P [T] → 0.70 x 0.50 → 0.35→35%
2. Probability of a child <3 Kg → 0.5 2. Probability of child BW ≥ 2.5 Kg, female → 35%
3. BW < 2.5 , Male → 0.30 × 0.50 = 15%
4. BW < 2.5 , Female → 0.30 x 0.50 = 15%

MCQ. Prevelence of DM = 10%

Probability that all 3 persons randomly selected have DM?
1 1 1
10 10 10

Each event is independent to each other

1 1 1 1
× × = = 0.001
10 10 10 1000

ODDS
• Chances of occurrence of a specific event relative to its non-occurrence
Probability
• ODDS =
1 - Probability

• E.g., Probability of Mr. Ram developing MI in his lifetime is 75%. What are the odds of developing MI ?
0.75
– ODDS = =3:1
0.25

TREE DIAGRAM
For representing A sequence of Events & their probabilities.
• Records all possible outcomes in Clear uncomplicated manner.
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Locations, Probability, Miscellaneous

FIG. 2: TREE DIAGRAM

For decision analysis

Fig. 3: Decision Tree

In Medicine, an Eg: ‘PEDIGREE’ Chart

Fig. 4: Pedigree Anal

BOX AND WHISKER PLOT

Definition: It is a Graphical presentation of Numerical Data through. its quartiles
• Box & whisker plot has a box in the center and two wishers in its sides.

Fig. 5: box and whisker plot

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PSM

• The box has got 2 ends, Quartile 1 (Q1) & Quartile 3 (Q3)
• The vertical line inside the box is called median also known as Q2 vThe whole data is divided into 4
Quartiles
• The lower end of one whisker represent the minimum value of the distribution.
• The higher end of other Whisker represent the maximum value of the distribution

IQR
Fig. 6: Box and whisker plot

Inter Quartile Range (IQR)

• It is the difference of Q3& Q1

BOX & WHISKER PLOT - SKEWNESS

Fig. 7: Skewness of CT

CANDLE- STICK CHARTS

Fig. 8
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Locations, Probability, Miscellaneous

Vertical Box &Whisker plot is also called “CANDLE – STICK CHARTS” In Normal Distribution - Mean=Median=Mode
In Right skewed data/ Positive skewed data / Top or Upward skew - Mean>Median>Mode
In Left skewed data / Negatively skewed data/Down or Bottom - Mean<Median<Mode

STEM & LEAF PLOT

It represents quantitative data in graphical format which helps us visualize the shape of distribution.
We are able to represent frequencies for different classes of values

Fig. 9 stem and leaf plot

• The left side is considered as stem and the one’s on right side is considered as leaves of different length.
Stem - Groups of scores
Leaf - Individual scores within each group

Example

Fig. 10: Stem and leaf plot

• Each number has to be placed in stem & leaf
For e.g.: 21 2 is depicted in stem 1 is depicted in leaf