DEPARTMENT OF NURSING SCIENCES,

BINHAM UNIVERSITY, KARU

COMMUNITY HEALTH NURSING

NSC 312

COMPILED

BY

SAMUEL GODWIN ATAYI

Definition of terms

 Epidemiology

The word epidemiology comes from three Greek words ''epi" meaning upon,

"demos"meaning people and "logos" meaning the study of. In other words,

epidemiology has its roots in the study of what befalls population.

Epidemiology is define as the study of the distribution and determinants of

health-related events in specified populations, and the application of this study

to the control of health problems.

Epidemiology is data-driven and relies on a systematic and unbiased approach

to the collection, analysis, and interpretation of data. Basic epidemiologic

methods tend to rely on careful observation and use of valid comparison

groups to assess whether what was observed, such as the number of cases of

disease in a particular area during a particular time period or the frequency of

an exposure among persons with disease, differs from what might be expected.

In short epidemiology is the study of 3Ds: that is, the study of diseases

frequency, distribution of disease and determinants of disease in human

population.

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Some terminologies Used in Epidemiology

 Infectious Agents

An infectious agent is any organism or agent that is capable of producing

infection or infectious diseases. Examples:- Bacteria, Viruses, Protozoa, Fungi,

Helminthic, Parasites etc

 Infection

Infection is the successful invasion of the body by micro organisms. Please note

that infection is not the same as infectious disease.

 Reservoir

A reservoir is any human being, animal, anthropod, plants, soil or inanimate

matter in which an infectious agent normally lives and multiply and depends

primarily on for survival. Man is the only reservoir of infection from many

diseases (man to man). Occasionally, an animal and environment may serve as

the reservoir. The reservoir may or may not be the source from which an agent

is transferred to a host. For example, the reservoir of Clostridium botulinum is

soil, but the source of most botulism infections is improperly canned food

containing C. botulinum spores.

 Human reservoirs:

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Many common infectious diseases have human reservoirs. Diseases that are

transmitted from person to person without intermediaries include the sexually

transmitted diseases, measles, mumps, streptococcal infection, and many

respiratory pathogens. Because humans were the only reservoir for the

smallpox virus, naturally occurring smallpox was eradicated after the last

human case was identified and isolated. Human reservoirs may or may not

show the effects of illness.

 Animal reservoirs.

Humans are also subject to diseases that have animal reservoirs. Many of these

diseases are transmitted from animal to animal, with humans as incidental

hosts. The term zoonosis refers to an infectious disease that is transmissible

under natural conditions from vertebrate animals to humans. Long recognized

zoonotic diseases include brucellosis (cows and pigs), anthrax (sheep), plague

(rodents), trichinellosis/trichinosis (swine), tularemia (rabbits), and rabies (bats,

raccoons, dogs, and other mammals).

 Environmental reservoirs.

Plants, soil, and water in the environment are also reservoirs for some

infectious agents. Many fungal agents, such as those that cause histoplasmosis,

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live and multiply in the soil. Outbreaks of Legionnaires disease are often traced

to water supplies in cooling towers and evaporative condensersthat act as

reservoirs for the causative organism Legionella pneumophila.

 Zoonosis

This is an infectious disease transmissible under natural conditions from

vertebrae animal to man. For example, rabies, Ebola, Lassa fever

 Susceptible Host

This refers to the sick person that the infectious agents have entered and

manifest itself. They may include people with chronic illness, immune

compromised people (People with a weakened immune system), Unimmunized

people, elderly, Very young people (Babies and Children), Anyone. Infectious

agents reproduce itself in such manner that it can be transmitted to successive

host.

 Incubation Period

This is the period between the exposure to an infectious agent and the

appearance of the first signs and symptoms of the disease.There are

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characteristics that influence disease/illness formation in the body. These are:

infectivity , pathogenicity, virulence, antigenic power.

 Infectivity

This refers to the ability of a pathogen to establish an infection. More

specifically, infectivity is a pathogen's capacity for horizontal transmission that

is, how frequently it spreads among hosts that are not in a parent-child

relationship. The measure of infectivity in a population is called incidence ( that

is the proportion of persons exposed to an infectious agent who become

infected by it).

 Pathogenicity

Pathogenicity is defined as the absolute ability of a micro-organisms to cause

disease/damage in a host. An infectious agent is either pathogenic or not.

 Virulence

The virulence of a microorganism is a measure of the severity of the disease it

causes. The severity or harmfulness of a disease is refers to as virulence.

 Antigenic Power or Antigenic variation or Antigenic alteration

These refers to the mechanism by which an infectious agent such as a

protozoan, bacterium or virus alters the proteins or carbohydrates on its

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surface and thus avoids a host immune response. Antigenic variation can result

from gene conversion, site-specific DNA inversions, hypermutation, or

recombination of sequence cassettes.

 Resistance

This is the sum total of body mechanism that provides a barrier to the progress

of invasion or multiplication of infectious agents and damage their toxic

products. This is made possible through immunity.

 Carrier

A carrier is someone who though has disease causing organism in his body but

does not show any sign of infection. The carrier has the ability to harbour and

disseminate the parasite without showing any clinical evidence of infection.

There are times when even carriers of a disease are more than those showing

the signs of the disease. They often become chronic carriers but this does not

last long. Some of the disease known to have carriers include: cholera,

salmonella typhi, poliomyelitis and diphtheria.

Carrier is a person with inapparent infection who is capable of transmitting the

pathogen to others.

 Types of Carrier

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 1) Asymptomatic or passive or healthy carriers are those who never

experience symptoms despite being infected.

2) Incubatory carriers are those who can transmit the agent during the

incubation period before clinical illness begins.

3) Convalescent carriers are those who have recovered from their illness

but remain capable of transmitting to others.

4) Chronic carriers are those who continue to harbor a pathogen such as

hepatitis B virus or Salmonella Typhi, the causative agent of typhoid

fever, for months or even years after their initial infection. Hence,

transmitting it to others.

 Immunity

This is the resistance usually associated with possession of antibodies having

specific actions on the micro-organism concerned with a particular infectious

disease or its toxin. An individual is considered immune when he possesses

specific protective antibodies or cellular immunity as a result of previous

infection or immunisation or by previous experience.

Immunity can be natural or acquired. Natural is inherent in the individual or

specie and it is independent of previous infection. Acquired immunity can be

active and passive. Active acquired immunity can be natural or induced, while

passive acquired may be natural/trans-placental or passive induced.

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  Active Immunity

This is the immunity an individual develops as a result of infection or specific

immunisation and usually associated with antibodies or cells having a specific

action on the disease or toxin. This can be acquired through any of the

following: After infection e.g. measles, After in-apparent infection e.g.

poliomyelitis, After immunisation

 Passive Immunity

This is the transference of antibodies produced in one body to another to

induce protection against disease. This is useful for individual who cannot form

antibodies or for the normal host who takes time to develop antibodies after

active immunisation. Here, the body depends solely on ready-made antibodies.

This can be derived from any of the following:when an antibody is

administered, transfer of maternal antibodies across the placenta, transfer of

lymphocytes to induce passive cellular immunity.

 Herd Immunity

This is the level of resistance of a community or group of people to a particular

disease. It provides an immunological barrier to the spread of disease in the

human herd.

 Vaccine

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This is an immuno-biological substance designed to produce specific protection

against a given disease. It stimulates the production of protective antibody and

other immune mechanisms. It may be prepared from live modified mechanism

or inactivated or killed organisms.

 Epidemics

This can be defined as the occurrence in a community or region or a member of

a defined population or a group having illness of a similar nature in excess of a

normal expectancy in that population.

In epidemics, any kind of disease or injury may be involved and there are no

universally applicable number of cases and no clear geographical extent e.g.

food poisoning.

 Pandemic:

If an infection can affect a large population which cuts across boundaries not

really world-wide and not specific to time.

 Endemic :

A disease can be said to be endemic in contrast to epidemics. This is a constant

spread of a disease or an infective agent within a given geographical area. It is

the usual prevalence of a given disease within an area.

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  Hyperendemic

This is a term that expresses a persistent intense transmission of the disease

e.g. malaria

 Epizootic and Enzootic

These are expressions that are equivalent of epidemic and endemic as they

apply to animals e.g. epizootic of yellow fever in monkey which precedes that

of yellow fever in man.

 Pathogens:

These are agents that cause infections or diseases, especially microorganisms

like bacteria, protozoa, viruses, fungi and parasites like helminthes and ecto-

parasites.

 Disease surveillance

This is an epidemiological practice by which the spread of disease is monitored

in order to establish patterns of progression. The main role of disease

surveillance is to predict, observe, and minimize the harm caused by outbreak,

epidemic, and pandemic situations, as well as increase knowledge about which

factors contribute to such circumstances. A key part of modern disease

surveillance is the practice of disease case reporting.

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  Outbreak

This is a sudden increase in occurrences of a disease in a particular time and

place. It may affect a small and localized group or impact upon thousands of

people across an entire continent.

 Portals of Entry into the Host

To cause disease, the infectious agent must first gain entry into the human

body. Common portals of entry include: Respiratory tract, Gastrointestinal

tract, Mucosa (e.g., conjunctiva, nose, mouth), Genitourinary tract, Breach of

skin integrity, Mosquito bite

 Portal of exit

Portal of exit is the path by which a pathogen leaves its host. The portal of exit

usually corresponds to the site where the pathogen is localized. For example,

influenza viruses and Mycobacterium tuberculosis exit the respiratory tract,

schistosomes through urine, cholera vibrio in feces, Sarcoptesscabieiin scabies

skin lesions, and enterovirus 70 which is a cause of hemorrhagic conjunctivitis

exit in conjunctival secretions. Some blood borne agents can exit by crossing

the placenta from mother to fetus (rubella, syphilis).

 Mode of transmission

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Since micro-organisms cannot travel on their own; they require a vehicle to

carry them to other people and places. This refers to how germs gets around

and are transferred from surface to another this can be through Contact with

infected person or contaminated object (hands, toys, sand, equipment etc),

through Droplets or air (when infected person speak, sneeze or cough), through

water or contaminated food, through Vector ( Mosquitoes, Tse-tse fly etc.) etc.

 Vector

Vectors are living organisms that can transmit infectious pathogens between

humans, or from animals to humans. Many of these vectors are bloodsucking

insects, which ingest disease-producing microorganisms during a blood meal

from an infected host (human or animal) and later transmit it into a new host,

after the pathogen has replicated. Often, once a vector becomes infectious,

they are capable of transmitting the pathogen for the rest of their life during

each subsequent bite/blood meal. Examples are: Mosquitoes ( Causing Malaria

fever and Yellow fever), Black fly ( causing Onchoceriasis, that is, river

blindness), Tse-tse fly ( Causing trypanosomiasis, that is, Sleeping sickness),

Aquatic snail ( causing Schistosomiasis, that is, bilharziasis) etc.

 The chain of infection

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The process of infection can be represented as a chain, along which

microorganisms are passed from a source to a vulnerable person. Breaking a

link at any point in the chain will control the risk of infection by preventing the

onward transmission of microorganisms.

The Diagram below shows the chain of infection.

Fig 1: Infection chain

Transmission of infectious disease may be interrupted or chain of infection

broken when:

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  The infectious agent is eliminated, inactivated or cannot survive in the

reservoir (E.g. rapid identification and management of organisms,

cleaning and disinfecting of the environment).

 The portal of exit is managed through good infection prevention and

control practices (E.g. Hand Hygiene, appropriate use of PPE, safe

packaging and disposal of waste).

 Transmission does not occur due to good infection prevention and

control practices (E.g. Hand Hygiene, isolation of infected patients, air

flow control where appropriate).

 The portal of entry is protected (E.g. Aseptic non-touch technique, safe

catheter care, wound care).

 Reducing the susceptibility of patients receiving healthcare (E.g.

Treatment of underlying disease, recognising high risk patients).

 The difference between Colonisation and Infection

a) Colonisation

Colonisation is when microorganisms, including those that are pathogenic, are

present at a body site (E.g. on the skin, mouth, intestines or airway) but are

doing no harm and are not causing symptoms of infection. The person

colonised is also called ‘a carrier’. For example, the skin is normally colonised by

coagulase negative Staphylococci and can also be colonised by pathogenic

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Staphylococcus aureus. Colonisation occurs in some 30% of the population and

whilst the microorganisms cause no harm if they remain on the skin, if

transferred to another site e.g. a wound, or another person it can cause an

infection.

b) Infection

Infection is the process where an infectious agent (microorganism) invades and

multiplies in the body tissues of the host resulting in the person developing

clinical signs and symptoms of infection (such as Increased temperature, rigors,

rash).

 Infection control

According to the Centers for Disease Control and Prevention, one out of every

20 hospitalized patients will contract a healthcare-associated infection or

nosocomial infection. The spread of these infections, however, can be

controlled. There are several simple and cost-effective strategies that can help

prevent infections, from the basic tenet of hand hygiene to the team-oriented

approach of Comprehensive Unit-based Safety Programs.

The five basic principles of infection control are using personal protective

equipment (PPE), disinfecting surfaces and equipment, good personal hygiene,

careful wound care and treating underlying diseases.

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  Infection Control Principles

1. Personal Protective Equipment (PPE)

PPE is one of the best ways to stop infections from spreading.It blocks anything

from coming out of the ‘portal of exit’and potentially causing an infection in

another person. This is just one part of the chain of infection.In healthcare

organisations, there are numerous types of PPE that you can use. These

include: Aprons, Masks, Gloves, Hair nets, Booth, Google etc. Usually in

hospitals these are single-use items. As a result, you need to learn how to

properly “put it on, use it, remove it and dispose of it”.

2. Disinfecting Surfaces and Tools.

Another very important principle for controlling infection is disinfecting all

surfaces and equipment after use. This is because there could be blood, bodily

fluids or other harmful substances on them that could cause an infection. By

sanitising surfaces and tools, you prevent the ‘transmission’ stage in the chain

of infection. If your organisation reuses syringes, this is really important as you

can prevent blood-borne diseases. The best-case scenario is to dispose of them

after use, but if you cannot, then make sure to disinfect any needles.

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 3. Good Personal Hygiene

Good personal hygiene is essential for preventing the spread of infection.The

most important thing to do is wash your hands regularly. You need to properly

wash your hands before and after work activities, as well as eating or drinking.

If you don’t, then you may pass on bacteria or even viruses on your hands to a

patient. Bacteria is present on the skin most of the time, but it is harmless. It

becomes dangerous when you touch parts of others like an open wound.

4. Careful Wound Care

You should try and protect any ‘portal of entry’ as much as possible, like open

wounds.To do this, use antiseptic wipes to prevent bacteria from entering an

open wound. You should avoid touching an open wound at all costs. Cuts are

one of the most common injuries, and its important to be careful even with the

smallest of cuts. After cleaning a wound, you should apply a clean bandage.

Never use a plaster or bandage that has already been opened, as it will not be

disinfected. Applying a dirty bandage to an open wound is a sure-fire way of

getting an infection or infectious disease

5. Treating Underlying Diseases.

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Treating underlying diseases and knowing if you have a high-risk patient helps

hugely in combating healthcare associated infections (HCAIs). These are

“infections that develop in a patient, as a direct result of receiving healthcare”.

Its important to treat the underlying issue as quickly as possible, to prevent

infections from spreading further. It is also good if you can limit the number of

visitors, as they may pick-up the infection themselves.

 strategies for prevention of infections.

1) Hand Hygiene.

According to the CDC, this is the simplest approach to preventing the spread of

infections and needs to be incorporated into the culture of the organization.

Surgical team personnel should wash their arms and forearms before a

procedure and put on sterile gloves, according to CDC guidelines for infection

control.

2) Environmental hygiene.

One of the most common sources of transmission of infection is environmental

surfaces. Certain types of microbial bacteria are capable of surviving on

environmental surfaces for months at a time, When healthcare providers or

patients touch these surfaces with their skin, the bacteria can be transmitted,

causing infection. Thus, it is essential that the environment be kept clean and

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disinfected. Patients and their families are now the biggest advocates of

medical safety, and they should be included in infection prevention protocols,

especially with respect to maintaining a clean and sanitary environment. It is

also important to involve multidisciplinary environmental hygiene teams in

meetings regarding adherence to infection prevention protocols.

3) Screening and cohorting patients.

Consistent screening of patients must be done. However, it is essential that

patients who are suffering from the same disease or infection should be kept

together in a designated area.This is essential to ensure that cross infections do

not happen. Infections can spread easily from one patient to another if they are

being treated in the same area, with the same staff and shared patient care

equipment. Some infectious agents are even airborne.

4) Vaccinations.

The staff at a healthcare organization may sometimes be the cause of the

spread of infections. They come into contact with patients with different types

of diseases and may contract infections, according to the CDC. As a result,

organizations must make sure that recommended vaccinations are being

administered to their staff as recommended. "Keeping healthcare professionals

healthy pays dividends," as it results in decreased transmission risk to co-

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workers and patients. General public vaccinations can also be done during

outbreak.

5) Surveillance.

Through surveillance, organizations should gather data regarding infection

patterns at their facility. They should also regularly assess current infection

prevention protocols. Having a robust infection surveillance program helps

organizations measure outcomes, assess processes of care and promote patient

safety. Sharing the data that the infection surveillance program gathers is the

next step. Communicate, display and discuss all process and outcomes

measures with all stakeholders.

6) Antibiotic stewardship.

The misuse and overuse of antibiotics can put patients at a risk of contracting

infections, according to the Association for Professionals in Infection Control

and Epidemiology. Inappropriate antibiotic use may also result in patients

becoming resistant to some drugs. If those patients contract an infection, it

becomes harder to treat them and the risk of it spreading increases.

7) Care coordination.

Breakdown of communication in the preparation, planning and care

management among various care providers during the care transition process

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can lead to infections that could otherwise be avoided. It is important that

during transition of care or shifting handover health workers communicate the

conditions of their patients in details.

8) Following the evidence.

Keeping abreast of the latest findings regarding the spread of infections and

strategies for prevention is essential for a successful infection prevention

program.

9) Appreciating all the departments that support the infection prevention

program.

An organization's culture may need to shift from thinking that only infection

preventionists are accountable for infection prevention, because every patient

encounter throughout the care continuum presents all healthcare workers with

an infection prevention opportunity. All caregivers are accountable, and to

encourage infection prevention protocols, healthcare professionals should

show appreciation for all the people who help keep infections at bay.

10) Comprehensive Unit-based Safety Programs.

The Comprehensive Unit-based Safety Program is a structured strategic

framework for patient safety improvement that integrates communication,

teamwork and leadership, according to the Agency for Healthcare Research and

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Quality. Each unit should have its own infection prevention champions, with

these individuals becoming an extension of the infection prevention and

control department.

 Elimination of the reservoir of infection:

A. Isolation:

Is used to separate ill persons who have a communicable disease from those

who are healthy. Isolation restricts the movement of ill persons to help stop the

spread of certain diseases. For example, hospitals use isolation for patients with

infectious tuberculosis.

B. Quarantine.

Is used to separate and restrict the movement of well persons who may have

been exposed to a communicable disease to see if they become ill. These

people may have been exposed to a disease and do not know it, or they may

have the disease but do not show symptoms. Quarantine can also help limit the

spread of communicable disease.

A quarantine is a restriction on the movement of people and goods which is

intended to prevent the spread of disease or pests. It is often used in

connection to disease and illness, preventing the movement of those who may

have been exposed to a communicable disease, but do not have a confirmed

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medical diagnosis.The term is often used synonymously with medical isolation,

in which those confirmed to be infected with a communicable disease are

isolated from the healthy population.

Note:- Isolation and quarantine are used to protect the public by preventing

exposure to infected persons or to persons who may be infected.

C. Disinfection

The process of killing or inactivating harmful and objectionable bacteria, cysts

and other microorganisms (pathogenic) by various agents such as chemicals,

heat, ultraviolet light, ultrasonic waves, or radiation. Disinfection is usually

considered a 99+% kill compared to sterilization that generally attains 100% kill.

In order words, Disinfection does not necessarily kill all microorganisms,

especially resistant bacterial spores; it is less effective than sterilization, which

is an extreme physical or chemical process that kills all types of life.

Note:- Disinfectants are antimicrobial agents designed to inactivate or destroy

microorganisms on inert surfaces. Examples hand sanitizers etc

 Elements of contact tracing

In principle, contact tracing is broken down into four basic elements, namely,

contact identification, contact listing, contact follow-up and contact discharge.

The four elements of contact tracing are described below.

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 (1.) Contact identification

Contact identification is an essential part of epidemiologic investigation for all

cases meeting the standard/surveillance case definitions of that particular

infectious disease. These cases are classified as suspected, probable or

confirmed. Epidemiologic investigation is also conducted for all deaths, either

in the community or in a health facility, that are attributable to the infectious

disease. The process of verifying the cause of death is called verbal autopsy,

which aims to establish the likely cause of death and identify chains of

transmission. The tool for conducting an epidemiologic investigation is the case

investigation form. The use of a comprehensive and standardized case

investigation form is recommended. The epidemiologist/surveillance officer

conducting the epidemiologic investigation should complete case investigation

forms for all the infectious disease say Ebola Virus Disease (EVD) cases and

deaths meeting the standard/surveillance case definition. After completing the

case investigation form, the epidemiologist/surveillance officer should

systematically identify potential contacts.

Contact identification therefore begins from a case. Identification of contacts is

done by asking about the activities of the case (whether alive or dead) and the

activities and roles of the people around the case (alive/dead) since onset of

illness. Although some information can be obtained from the patient, much of

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the information will come from the people around the patient. In many

instances, the patient will have died or have already been admitted to the

isolation facility, with limited access. It is mandatory for the

epidemiologist/surveillance officer to visit the home of the patient. The

following information should be obtained:

a) All persons who lived with the case (alive/dead) in the same households

since onset of illness.

b) All persons who visited the patient (alive/dead) either at home or in the

health facility since onset of illness.

c) All places and persons visited by the patient since onset of illness e.g.

traditional healer, church, relatives, etc. All these places and persons

should be visited and contacts identified.

d) All health facilities visited by the patient since onset of illness and all

health workers who attended to the patient (alive/dead) without

appropriate infection prevention and control procedures.

e) All persons who had contact with the dead body from the time of death,

through the preparation of the body and the burial ceremonies.

f) During the home visit, the contact tracing/follow-up teams should ask

about persons who might have been exposed to the patient (alive/dead)

but were not identified and listed as contacts through the above process.

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 g) Priority should be given to those high risk categories of contacts, persons

who within the period of the disease incubation period:

i. Touched the patient’s body fluids (blood, vomit, saliva, urine, faeces) or

had contact with the patient.

ii. Had direct physical contact with the body of the patient (alive/dead).

iii. Touched or cleaned the linens or clothes of the patient.

iv. Slept or ate in the same household as the patient.

v. Have been breastfed by the patient (i.e. babies).

vi. Health care workers who had contact or suffered a needle-stick injury

from a contaminated instrument while attending to a probable or

confirmed case.

vii. Laboratory workers who had direct contact with specimens collected

from suspected patients without appropriate infection prevention and

control measures.

viii. Patients who received care in a hospital where infected patients were

treated before the initiation of strict isolation and infection prevention

and control measures (hospital- acquired infection – the circumstance of

exposure should be critically examined).

The exposure information should be verified and double-checked for

consistency and completeness during re-interview in later visits to ensure that

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all chains of transmission are identified and monitored for timely containment

of the outbreak.

(2.) Contact listing

All persons considered to have had significant exposure (falling in the

categories described above in contact identification) should be listed as

contacts, using the contact listing form. Efforts should be made to physically

identify every listed contact and inform them of their contact status, what it

means, the actions that will follow, and the importance of receiving early care if

they develop symptoms. The contact should also be provided with preventive

information to reduce the risk of exposing people close to them.

The process of informing contacts of their status should be done with skill and

empathy, since being a contact can be associated with serious health

outcomes. Avoid using alarming information, such as ‘ COVID-19 has no

treatment’ or ‘Ebola has a very high case fatality rate’.

Advise all contacts to:-

a) Remain at home as much as possible and restrict close contact with other

people.

b) Avoid crowded places, social gatherings, and the use of public transport.

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 c) Report any suspicious signs and symptoms related to the infection

immediately (provide telephone numbers for the contact follow-up

team, the supervisor or the hotline/call centre numbers). Explain that

getting early and good clinical care improves health outcomes, and

immediate evacuation from the home and isolation reduces the risk of

infecting family members.

Contact identification and listing, including the process of informing contacts of

their status, should be done by the epidemiologist or surveillance officer, not by

the local surveillance staff/community health worker performing the daily

follow-up. The local surveillance staff/community health worker should be

introduced during the initial home visit as the person who will conduct home

visits.

(3.) Contact follow-up

The epidemiologist/surveillance officer responsible for contact tracing should

assemble a competent team comprising local surveillance and appropriate

community members to follow-up all the listed contacts. This could include

surveillance staff/health workers from health facilities, community health

workers, volunteers e.g. from the Red Cross and community leaders.

An efficient contact tracing system depends on a relationship of trust with the

community, which in turn fosters optimum cooperation. Communities should

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have the confidence to cooperate with contact tracing teams and allow the

referral of symptomatic contacts to designated isolation facilities. Involving

appropriate community members (in particular local leaders) in contact tracing

is critical in cultivating this good relationship, trust and confidence.

The local surveillance and community volunteers should be involved as early as

possible in the response. The local surveillance staff and community health

workers should be closely supervised by trained epidemiologists/surveillance

officers.

The contact follow-up teams and their supervisors should be trained in a one-

day workshop to familiarize the team with basic information on the infectious

disease, procedures and tools for contact tracing, and the required safety

precautions. The training package should cover:

i. Basic facts about the infectious disease, transmission, and preventive

measures.

ii. The rationale and procedures for contact tracing/follow-up.

iii. Contact tracing/follow-up tools, Vital signs monitoring e.g temperature

monitoring, reporting, etc.

iv. Recommended infection prevention and control measures for contact

tracing teams.

v. Home-based preventive measures at onset of illness.

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vi. Home-based care for symptomatic contact

vii. Linkage/coordination with other response groups.

After the orientation, the contact follow-up teams should be equipped with all

the necessary tools, including:

a) Contact listing, contact follow-up, reporting and monitoring forms.

b) Pens.

c) Vital signs monitoring tools e.g Thermometers (preferably digital).

d) Alcohol-based hand rub solutions or hand sanitizers

e) Infectious disease fact sheets and posters.

f) Protocol for reducing risks of transmission at home

g) Guidelines for home-based care for symptomatic contacts

h) Important contact list (e.g. technical leads, supervisors, call centre,

ambulance, etc.).

i) Disposable gloves.

j) Mobile phones with sufficient credit or other devices for supervisors.

(4.) Discharge of contacts

Contact identification, listing and follow-up should start as soon as a suspected

case or death has been identified. However, follow-up of contacts for suspect

cases that test negative for infectious disease should stop and the contacts

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removed from the contact list.

Contacts completing the days of follow-up period (incubation period) should be

assessed on the last day. In the absence of any symptoms, the contacts should

be informed that they have been discharged from follow-up and can resume

normal activities and social interactions. The team should spend time with the

contacts’ neighbours and close associates to assure them that the discharged

contacts no longer poses a risk of transmitting the disease. If an employer

requests an official letter declaring the end of follow-up, this could be provided

by the response team. The contacts should ensure that they are not re-exposed

to symptomatic contacts or probable/confirmed cases of infectious disease.

 Recommended safety precautions for contact tracing teams

Since infectious disease cases are more likely to be discovered during contact

follow-up, contact tracing teams should take precautionary measures to

protect themselves during home visits.

The teams should abide by the following:-

1. Avoid direct physical contact like shaking hands or hugging.

2. Maintain a comfortable distance (more than 1metre)) from the person.

3. Avoid entering the residence.

4. Avoid sitting on chairs offered to you.

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 5. Avoid touching or leaning against potentially contaminated objects.

6. Always have a good breakfast before home visits to resist the temptation

of eating or drinking while visiting contacts.

7. Do not conduct home visits wearing personal protective equipment like

masks, gloves, or gowns.

8. If you must take the contact’s Vital signs e.g temperature:

a) Put on disposable gloves.

b) Have the contact turn around and take their vital signs e.g temperature

in the armpit.

c) Avoid touching the patient and step back to wait for the thermometer.

9. If the contact is visibly ill, do not attempt to take their Vital Signs e.g

temperature, but notify your supervisor.

10.As part of the overall safety of the response team, all members of the

contact tracing team should monitor their own temperature every

morning.

 Protection of susceptible Host: Preventing the transmission of

infectious diseases

(a) Immunization:- “Overwhelming evidence demonstrates the benefits of

immunization as one of the most successful and cost-effective health

interventions known”. Immunization avoids about 2–3 million deaths each

32
year, as well as serious disability from vaccine-preventable diseases including

Yellow fever, diphtheria, tetanus and pertussis, rubella, rotaviruses, polio,

pneumococcal diseases, mumps, measles, human papillomavirus, polio,

hepatitis B, and Haemophilus influenzae type b. To maximize immunization

coverage, national vaccination plans should provide for free or affordable

immunizations that are available from most health care providers, public

education campaigns to illustrate the importance and safety of vaccinations,

monitoring of vaccination rates and their impact on health outcomes, and

limited exceptions for individuals who for medical or religious reasons wish to

avoid vaccinations.

(b) Screening:- Screening individuals to determine if they have been infected

with or exposed to an infectious disease is a core public health strategy.

Screening enables health care providers to begin treatment in a timely manner,

to manage co-morbidities more effectively, to encourage patients to reduce

high-risk behaviour and, in certain cases, to identify the need for compulsory

treatment. In addition to reducing the severity of illness, early treatment may

also reduce transmission rates. For example, early treatment with antiretroviral

drugs lowers the viral load of people with HIV and AIDS significantly

33
(c) Criminal law and mandatory disclosure laws:- The appropriate role of

criminal law in national efforts to prevent transmission of HIV and other

sexually transmissible infections or infectious disease is often controversial.

Public health laws often contain penalties for failing to comply with public

health orders made by authorities, or for engaging in behaviours that place

public health at risk. However, policy-makers should not ignore the potential

for unintended consequences arising from laws that create criminal offences

for recklessly exposing another person to infectious disease e.g HIV, or for

failing to disclose one’s health status such as HIV status to a sexual partner.

Laws like these may be intended to encourage personal responsibility in the

hope that individuals will modify their behaviour in order to avoid criminal

penalties. They may also be motivated by the belief that those who fail to

protect others from transmission, or from the risk of transmission, deserve

punishment. On the other hand, the broader impact of these laws on

transmission rates and public health can be negative.

(d) Compulsory treatment orders:- Although the right to consent to medical

treatment is a fundamental individual human right, there are circumstances in

which public health authorities may be justified in ordering the compulsory

diagnosis and treatment of individuals. Public health laws should authorize

compulsory treatment orders only in circumstances where the person in

34
question is unable or unwilling to consent to a diagnostic procedure or

treatment, and where their behaviour creates a significant risk of transmission

of a serious disease. For example, South Africa’s National Health Act states that

a health service may not be provided to a user without the user's informed

consent, unless “failure to treat the user, or group of people which includes the

user, will result in a serious risk to public health”.

(e) Limiting contact with infectious persons:- Isolating persons who have or

may have been exposed to a serious contagious disease, in order to prevent

transmission, is a long-established public health strategy that may be applied to

both individuals and groups. Where an outbreak of a serious, contagious

disease occurs, it will often be impractical or impossible to accurately identify

cases and carriers of disease. For this reason, public health laws should

authorize officials to evacuate or to order the closure of premises (e.g. markets,

schools and movie theatres) and to prevent access to public spaces where

people would otherwise gather. Since the closure of premises can affect

businesses and livelihoods, it is important for the operation of public health

orders to be reviewed regularly and to be based on public health

considerations, without discrimination on grounds of race, gender, tribal

background or other inappropriate criteria. Public health orders for the

evacuation or closure of premises may be coupled with orders to disinfect and

35
decontaminate premises, or to remove noxious articles (including objects, birds

and animals) that are contaminated with an infectious agent. Where the

confiscation or destruction of private property causes more than trivial

economic loss, public health laws should require reasonable compensation to

be paid to the owner. This principle can have an important benefit for public

health: laws that provide for just compensation are more likely to secure the

trust and voluntary cooperation of those who are poor and economically

vulnerable, and who for that reason are most likely to be adversely affected by

a public health order.

(f) Isolation of infected person:- Public health laws should authorize public

health officials to make orders for the isolation of infected individuals, and

prompt treatment

(g) Quarantine of those who have been exposed:- Those who have been

exposed to a serious contagious disease. As with treatment orders, however,

these restrictions on autonomy should only be used as a last resort and should

be minimally restrictive. For example, an infectious individual who does not

require medical attention may be effectively quarantined within his or her

home, rather than being confined in a hospital or other facility used as a

detention centre.

36
Laws authorizing mandatory confinement must also ensure that basic needs

are met, including adequate shelter, food, water and sanitation. They should

also provide for appropriate treatment and health care, and respect the

cultural or religious expectations of quarantined or isolated individuals to the

greatest possible extent.

(h) Other ways to protect the susceptible host from infection include:-

Adequate Nutrition, Healthy lifestyle through Behaviour change and

communication

 COMMUNICABLE DISEASE

Communicable diseases are infectious diseases that spread from person to

person, or sometimes from animals to people. They occur at all ages but are

most serious in childhood and aged. They are to a great extent preventable.

Some communicable diseases can be spread by casual contact such as cold, flu,

COVID-19 , tuberculosis etc from respiratory droplets, from coughing, sneezing

or runny nose. Others require contact with blood from an infected individual,

as in the case of hepatitis B and AIDS virus. Some others require intimate

contact with infected individual‘s body fluids or genitalia, such as herpes,

syphilis, Lassa fever, Ebola etc. The causative agents of communicable diseases

are microorganisms or pathogens that invade the body and are often referred

37
to as infectious diseases. Examples of the microorganisms include, bacteria,

fungi, viruses and protozoa. Their invasion of the body could lead to acute or

chronic disease, accompanied by pathological alterations and manifested in

adequate clinical symptoms in host. These symptoms are triggered in the host

by;

 Pathologic effects of infectious agent, toxins, enzymes, and junctional

membrane-components, virulence-factors, viral infection-caused

cytolysis and cell-proliferation.

 Immuno-response of attacked organism (inflammatory, allergic,

autoimmune reactions)

Hence, communicable diseases are spread through the following: Air, Droplet,

contact with blood and body fluid, water, ingestion of contaminated food,

Casual contact with infected person or contaminated objects among others.

 Classification of Communicable diseases and infections

Communicable diseases are caused by pathogens, which are agents that cause

infections or diseases, especially microorganisms like bacteria, protozoa,

viruses, fungi and parasites like helminthes and ecto-parasites.

 Bacterial Infections:

38
Bacteria are a simple microscopic form of life. They can produce all the proteins

needed for life. They use DNA as their genetic material. They are called

prokaryotes because they do not contain a nucleus and membrane-bound

organelles. In contrast, eukaryotes (animals, plants, fungi, and protozoa) do

contain a nucleus or cellular organelles.Bacterial diseases of man include

streptococcus, staphylococcus and E. coli among many others. They cause wats,

food poisoning, tuberculosis, whooping cough, gonorrhea, scarlet fever,

diphtheria, pneumonia, cholera, typhoid fever , Syphilis, Leprosy etc;

 Viral infections:

Viruses can have either DNA or ribonucleic acid (RNA) as the genetic material.

Viroids are smaller than viruses and are known to be plant pathogens.

Examples of viral infections of man include common cold, viral hepatitis,

influenza, herpes, poliomyelitis, papilloma, ebola and HIV/AIDS, Rubella,

Mumps, Measles, Chicken Pox, Influenza, COVID-19 among many others.

 Parasitic infections:

A parasite is an organism that lives in close proximity to a host and completely

depends on it. Parasites receive their nutrition from the host, using the host‘s

blood or absorbing nutrients in the host‘s intestine. Although the parasites

rarely kill the host, they do inflict significant harm. Parasites adversely affect

39
the quality of life for companion animals and livestock; they also reduce

production efficiency of livestock and may result in the death of an animal.

They are classified into two as:-

1. Internal Parasites (Endo-parasites):

Internal parasites include protozoa, roundworms or nematodes (e.g Guinea

worm, Ascariasis), flatworms or trematode (e.g Paragonimiasis) , cestodes or

tapeworms (e.g Taenia Solium , Taenia Saginata) and larvae of some flies.

2. External Parasites (Ecto-parasites):

These can be either insects or arachnids (ticks and mites, bugs, flies, lice, or

mosquitos). Examples of insects that are ecto-parasites are, lice and fleas or are

blood-sucking true flies such as mosquitos, and tsetse flies. These insects are

frequently also vectors or secondary hosts for pathogenic bacteria (e.g., the

plague causing bacteria causing bubonic plague: Yersinia pestis), or are

parasites such as protozoa (trypanosomes causing sleeping sickness,

plasmodium causing malaria), tapeworms, and heartworms.

 Protozoa Infection

Protozoa are single-celled eukaryotes with a nucleus and intracellular

organelles. They impact their hosts as parasites, as zoonotic diseases, and by

40
symbiotic ciliates participating in the fermentation in the caecum. Examples are

Trypanosomes causing sleeping sickness, plasmodium causing malaria

 Fungal infections:

These include athletic foot, ringworm, candidiasis, Histoplasmosis, Oral thrust

etc

 Helminthic Infection:

These are worms infestation e.g Round worm, Guinea worm, Tape worms, flat

worms, filariasis , Onchocerciasis among other worn infestation in human.

 Prevention of Diseases

There are four major way of preventing infectious diseases:-

1. Primordial prevention.

Primordial prevention is defined as prevention of risk factors beginning with

change in social and environmental conditions in which these factors are

observed to develop, and continuing for high risk age groups. Primordial

prevention is a relatively new concept, and is receiving special attention in the

prevention of chronic diseases. For example, many adult health problems such

as obesity and hypertension have their early origins in childhood, because this

is the time when lifestyles are formed. It is therefore important to change the

41
milieu that promotes major risk factor development. Primordial prevention

calls for changing the socio-economic status of society. A better socio-

economic status correlates inversely with lifestyle factors like smoking,

abnormal food patterns and exercise. It is also prevention of emergence or

development of risk factors in countries where they have not yet appeared.

Primordial prevention efforts are directed towards discouraging children from

adopting harmful life styles. The main intervention is therefore through

individual and mass education. Examples of primordial prevention actions may

include national policies and programmes on nutrition involving the agricultural

sector, the food industry, and the food import-export sector or programmes to

promote regular physical activity. Responsibilities for primordial prevention rest

with the government, professional and non-governmental organizations,

industry, hospitals, health clinics, health practitioners and health-care workers.

2. Primary prevention.

Primary prevention is any effort undertaken to prevent the occurrence of

diseases. This is one of the most important steps in disease prevention and

control and even though all health care services play a role, this is most often

the domain of public/community health services. Publicly funded childhood

immunization programs are examples of primary prevention. Primary

prevention also includes promoting healthy lifestyles and education specific to

42
preventing the transmission of communicable diseases in recreational/personal

service settings and preventing non-Communicable Diseases in the populace.

The provision of hepatitis A and hepatitis B vaccine to people infected with

hepatitis C is an example of primary prevention (of hepatitis A and hepatitis B).

So primary prevention is directed towards prevention of disease occurrence.

3. Secondary stage of communicable disease prevention.

Unfortunately, it may not be possible to prevent all communicable diseases and

illnesses. However, by implementing the secondary prevention approaches, it is

possible to detect diseases in a timely fashion and possibly slow the

progression of disease within the individuals or disease transmission in the

population. Understanding risk factors in the population and implementing

methods of screening allows us to detect diseases at their early stages, that is

Early diagnosis and treatment. The earlier the disease is diagnosed, and treated

the better it is for prognosis of case and for the prevention of occurrence of

other secondary cases. For instance, screening for sexually transmitted

infections (STIs) and blood borne pathogens allows health care providers to

offer interventions that prevent secondary complications. Routine pap smears

can allow for early detection and treatment of cellular abnormalities from a

human papillomavirus (HPV) infection that left untreated may lead to cervical

cancer. Screening people living with HIV or AIDS for co-infection with

43
tuberculosis is also an example of secondary prevention (of tuberculosis).

Hence, Secondary Prevention is directed towards early diagnosis and prompt

treatments so as to prevent development of complications.

4. Tertiary stage of communicable disease prevention.

Tertiary prevention approaches include the efforts of health care providers to

minimize the effects of an agent and prevent disability as a result of infection.

The provision of antiviral treatment to people infected with hepatitis C virus or

people living with human immunodeficiency virus (HIV) or acquired

immunodeficiency syndrome (AIDS) is an example of tertiary prevention.

Interventions that should be accomplished in the stage of tertiary prevention

are disability limitations and rehabilitation.

Note:-

 Impairment is any loss or abnormality of psychological, physiological or

anatomical structure or function.

 Disability is lack of ability to perform an activity in the manner or within

the range considered normal for the human being.

 Handicap is termed as a disadvantage for a given individual, resulting

from an impairment or disability, that limits or prevents the fulfillment of

44
 role in the community that is normal (depending on sex, age, and social

and cultural factors) for that individual.

 Rehabilitation on the other hand is the combined and coordinated use of

medical, social, educational, and vocational measures for training and

retraining the individual to the highest possible level of functional ability.

 NON-COMMUNICABLE DISEASE

Non-communicable diseases are chronic conditions that do not result from an

(acute) infectious process. They can also be defined as diseases that have

prolonged course, that do not resolve spontaneously, and for which a complete

cure is rarely achieved.

Traditionally, diseases characterized as non-infectious and of chronic nature are

grouped together as NCDs. NCDs include diseases such as diabetes,

cardiovascular diseases, mental disorders, neuro-degenerative disorders and

injuries.

Cardiovascular diseases, cancers, chronic respiratory diseases and diabetes make

the largest contribution to mortality in the majority of developing countries and

economies such as Nigeria.

 Classification of non-communicable diseases:-

The major categories of these NCDs are;

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1. Cardiovascular disorders and conditions of the heart:- Cardiovascular

disease (CVD) is a group of disorders of the heart and blood vessels, and

may include coronary heart disease, stroke, congestive heart disorder,

rheumatic heart disorder, hypertension etc.

2. Rheumatoid disorders (anemia):- Examples include iron deficiency

anemia, pernicious anemia, anemia of chronic diseases, hereditary

hemolytic disorder (sickle cell anemia).

3. Respiratory disorders:- Examples include asthma, lung cancer etc

4. Renal and genitourinary problems:- Leading cause of death, high

underdiagnoses rates and 90% of deaths occur in low-income countries.

Examples include acute renal failure, chronic renal failure.

5. Gastric and endocrines disorders:These include peptic ulcer, diabetes

mellitus,diabetes insipidus, cirrhosis of the liver, intestinal obstruction.

Diabetes is a disorder of metabolism. There are 4 types: Type 1, Type 2,

Gestational, and Pre- diabetes (Impaired Glucose Tolerance). Type 2 is

caused by modifiable risk factors and is the most common worldwide.

6. Benign and malignant tumors: This is the generic term for a large group

of diseases that can affect any part of the body. They are known for rapid

creation of abnormal cells that grow beyond their usual boundaries, and

which can then invade adjoining parts of the body and spread to other

organs. They are divided into benign tumors and malignant tumors.

46
 Examples are lung cancer, breast cancer liver cancer, colon and rectal

cancer,

7. leukemia Chronic neurologic disorders: Examples include Alzheimer‘s,

dementias.

8. Unintentional injuries: Example are those from traffic crashes, sports

injuries

9. Arthritis/Musculoskeletal diseases: Examples are muscles wasting and

joint diseases.

Note: it has been shown that there are many cases of interactions between

NCDs and infectious disease. Examples include;

Diabetes, TB and maternal health: People with diabetes are three times more

likely to develop active tuberculosis (TB). Gestational diabetes (GDM), maternal

undernutrition and obesity can lead to retarded intra-uterine growth and small

babies.

HIV and metabolic syndrome: Chronic inflammatory state in HIV adversely

affects body fat composition. Anti-retroviral therapy increases the risk of

metabolic syndrome and related NCDs.

Childhood malnutrition and later obesity: Preterm, large and small babies:

independent risk factors for diabetes in adult life (due to epigenetic changes

47
that are potentially reversible). Nutritional stunting (childhood under-nutrition)

is a risk factor for obesity in later life

Cancer and infectious disease: Hepatitis B (HBV), hepatitis C virus (HCV) and

some types of Human Papilloma Virus (HPV) increase the risk for liver and

cervical cancer respectively. HIV-infection substantially increases the risk of

cancer such as cervical cancer.

 Risk factors of Non-communicable Disease

Risk factor was generally defined as any attribute, characteristic or exposure of

an individual that increases the likelihood of developing a disease or injury. In

this context, risk factor is an aspect of personal behavior or lifestyle, an

environmental exposure, or a hereditary characteristic that is associated with

an increase in the occurrence of a particular disease, injury, or other health

condition.

Major non-communicable diseases (NCD) risk factors

The four main risk of factors of NCDs defined by WHO are:

1. Tobacco use.

2. Unhealthy diets

3. Physical inactivity, and

4. Alcohol

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While environmental risk factors of NCDs have not been given adequate

attention by WHO, a growing number of health, medical and scientific

associations are increasingly highlighting the link in environmental risk factors

such as air quality, chemicals including mercury, climate , and stress.

1) Tobacco use:-

Tobacco kills both users and those exposed to second-hand smoke. Alarming

global trends include early initiation of smoking, increased smoking among

women and shift to other forms like e-cigarettes as a potential fashion

accessory or harm reduction strategy. Worldwide, tobacco use is a major public

health problem that kills 6 million people annually. Smoking cigarettes causes

approximately 71 percent of all lung cancer deaths, 42 percent of chronic

respiratory disease, and 10 percent of heart disease. When people begin to use

tobacco at an early age, addictions are especially hard to overcome later in life.

Studies from the United States attest to widespread tobacco use among girls

and boys.

2) Unhealthy diet:-

Convincing evidence links NCDs with specific dietary components: salt, free

sugars (especially through use of sugar-sweetened beverages), fats, mainly

49
trans-fats and saturated fats and low fruit and vegetable consumption. Salt,

sugar and fat consumption in high-income countries is mainly from processed

food, requiring strong policy measures. In many low and middle income

countries, the source is still homecooked food, requiring an understanding of

food decision processes and multi-level contextualized interventions.

3) Physical inactivity:-

Current recommendations advocate moderate intensity physical activity of 150

minutes per week or 30 minutes per day for five days. In addition, sitting time

should be restricted to less than 2 hours at a stretch. Insufficient physical

activity and unhealthy diet can lead to high blood pressure and

overweight/obesity and are widely associated with Type 2 diabetes,

hypertension, and heart disease. As countries become wealthier and individuals

grow older, physical activity levels decrease, especially among women.

4) Unhealthy use of alcohol:-

The harmful use of alcohol includes the volume of alcohol drunk over time; the

pattern of drinking to intoxication; the drinking context and its public health

risks; and the quality or contamination of alcoholic beverages. Excessive alcohol

consumption is another risk behavior for NCDs and is associated with heart

50
disease and some cancers. Drinking also contributes to increased risk of road

traffic accidents, unprotected sex, intentional and unintentional injuries, poor

mental health, and gender-based violence.

 Modifiable risk factors , Non-modifiable risk factors , Metabolic risk

factors

Risk factors could be modifiable, non-modifiable factors and even Metabolic

risk factors.

1) Modifiable risk factor is a behavioral risk factor that can be reduced or

controlled by intervention, thereby reducing the probability of disease.

WHO has prioritized physical inactivity, tobacco use, alcohol use, and

unhealthy diets (increased fat and sodium, with low fruit and vegetable

intake) as modifiable risk factors. Exposure to environmental pollution is

also an example.

2) Non-modifiable risk factor is a risk factor that cannot be reduced or

controlled by intervention; for example, age, gender, race, and family

history (genetics).

3) Metabolic risk factors: Are risk factors related to the metabolic or the

biochemical processes involved in the body's normal functioning.

Behaviors (modifiable risk factors) can lead to metabolic/physiologic

51
 changes. WHO has prioritized the following four metabolic risk factors:

raised blood pressure; raised total cholesterol; elevated glucose;

overweight and obesity

 Prevention of Non-communicable Disease

A. Behavior modification e.g reducing intake of alcohol and cigarette

smoking, regular exercise, avoiding sedentary lifestyle

B. Stress management/Stress Coping strategies: These may include

exercise, dietary changes, yoga and meditation, relaxation techniques or

stress management courses, counseling, where indicated in the

treatment of NCDs. It is crucial to involve health professionals in this.

C. Enforcement of prevention and control measures

D. Engineering approaches in NCDs prevention and control

There have been several approaches to the reduction or elimination of

risk factors that drive many NCDs prevalence. Some of these approaches,

especially in the area of limiting tobacco use have resulted in the

development of new products that claim to reduce or even eliminate the

harmful effects of tobacco. Organizations such as Truth Initiative have

also sprung-up to support regulation that encourages the development

of consistently less harmful nicotine delivery alternatives that allow

smokers to quit tobacco altogether, or switch completely to a much less

52
 harmful product. Tackling NCDs is a concern for the United Nations,

which has included the reduction of premature mortality from NCDs as

one of their Sustainable Development Goals. This situation calls for

innovative approaches that improve the quality of healthcare, while

reducing total costs. According to World Health Organization, ―A good

health system should deliver quality services to all individuals, when and

where needed. The nature of service differs from country to country, but

in all cases oblige an improved health care efficiency, reliable information

on which base to take decisions and policies, safety and social benefits.

WATER SUPPLY

Water is an inorganic, transparent, tasteless, odorless, and nearly colorless

chemical substance, which is the main constituent of Earth's hydrosphere and

the fluids of most living organisms. Its chemical formula is H2O, meaning that

each of its molecules contains one oxygen and two hydrogen atoms, connected

by covalent bonds.

Water is essential for life. The amount of fresh water on earth is limited, and its

quality is under constant pressure. Preserving the quality of fresh water is

53
important for the drinking-water supply, food production and recreational

water use. Water quality can be compromised by the presence of infectious

agents, toxic chemicals, and radiological hazards. All living things require water

to grow and reproduce. 97% of the water on the Earth is salt water and only

three percent is fresh water;

USES OF WATER

Uses of water include agricultural, industrial, household, recreational and

environmental activities.

SOURCE OF WATER

There are three major suource of water which are:

1. Surface water.

2. Groundwater.

3. Rain water.

 Surface Water is found in lakes, rivers, stream, river, Pond, Pool,

reservoir, sea or ocean.

 Ground Water lies under the surface of the land, where it travels through

and fills openings in the rocks. Ground water, which is obtained by

drilling wells, is water located below the ground surface in pores and

spaces in the rock. Water found in well, borehole, springs etc.

54
  Rain water is the source of water that comes from above the clouds, this

water is very pure.

EXPLANATION OF SOURCE OF WATER

The following are the natural sources of water:-

1.) Ground Water

Groundwater is water that is found underground within rocks. Its presence

depends primarily on the type of rock. Permeable rocks have tiny spaces

between the solid rock particles that allow water and other fluids to pass

through and to be held within the rock structure. The layers of rock that hold

groundwater are called aquifers.

Groundwater in an aquifer is replenished by rain and other forms of

precipitation (any form of water, such as rain, snow, sleet or hail that falls to

the Earth’s surface). The level of water below ground is called the water table.

Groundwater can be extracted from wells or collected from springs. Ground

water is obtained by drilling.

A) Well Water

Well water as a source of water can be described by their depth, or by the way

they are constructed. Most especially they use different types of pump at the

surface to raise the water.

55
The pump is usually used to retrieve water and it go through an extensive

filtration or decontamination process either naturally or chemically. There are

two major types of well water

Shallow wells

Shallow wells and boreholes usually have a depth of less than 30 m, although

they can be as much as 60 m deep, especially in a very dry areas where the

water table is low. Wells can be excavated by hand if the soil is not too hard or

the water table is high.

Deep wells

These are wells that have been sunk with drilling machines designed for

constructing water extraction boreholes. These machines are able to penetrate

through harder material that cannot be tackled by hand digging and can

therefore pass through at least one impermeable layer of rock to a productive

aquifer underneath.

Deep well typically obtain water from depths ranging from 30 to 60 m, but

large urban supply boreholes can be much deeper than this. A casing of metal

or plastic pipe is usually necessary to line the borehole and prevent the soil and

rock from collapsing into it. The lower part of the casing must have suitable

openings to allow water to enter the borehole from the aquifer.

B) Borehole: is a form of underground water.

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2.) Rain Water

Rain water is the source of water that comes from above the clouds, this water

is very pure. Until it encounter something on it way down. However if it is

stored properly it may relinquish clean drinking water.

In regions where rainfall is abundant and frequent, rainwater can be a good

source of water supply for individual, families and some communities. The

storage of rainwater is particularly important in areas with a long dry season, or

where spring water is difficult to obtain.

The term rainwater harvesting is sometimes used. It simply means collecting, or

harvesting, rainwater as it runs off from hard surfaces and storing it in a tank or

cistern. Rainwater has several advantages. It is free, relatively clean and usually

reliable, even if it rains only once or twice a year, a rainwater harvesting

system can be easily constructed and maintained at low cost and is mainly

found in rural areas.

Apparently, if rainwater is used for water supply, it is important to ensure that

it is not contaminated by improper methods of storage, or by bird droppings

and leaves from the roof that it is collected from.

57
Rainwater may also be contaminated by pollution in the air, dust, dirt, paint

and other material on the roof or in roofing materials. All of these

contaminants can be washed into the storage tank or cistern.

3.) Surface Water

Surface water is easily the most abundant supply of natural water. The

downside is that most of the surface water on the planet is salt water so it is

not ideal for drinking for most living species. Surface water does play an

important part in our daily lives in addition to being a source of drinking water.

Surface water is used to produce hydro-electric power as a clean energy source

that is also renewable. Surface water is supplied by precipitation, springs and

ice melting from higher elevations and glaciers.

i.) Snow melt

Melting snow is another natural source of water when melted in great amounts

can yield clean drinking water especially once boiled

ii.) Lake And River Water

Lakes and rivers provide much water to wild animals and if cleaned and filtered

properly it could become clean enough to drink for humans. Most countries

with access to lakes and rivers use their water for human consumption. This

58
source of water supply is usually regularly replenished by various weather

events.

iii.) Salt water from oceans

Ocean water can effectively be processed for consumption through the

desalinisation process removing excess salt. Without this process the water

becomes counter-active and actually dehydrates you.

METHODS OF WATER TREATMENT/ PURIFICATION

The following methods of water treatment are followed systematically to purify

water for community Consumption.

1.) Aeration of water

Aeration treatment consists of passing large amounts of air through water and

then venting the air outside. The air causes the dissolved gases or volatile

compounds to be released from the water. The air and the contaminants

released from the water are vented. Aeration water treatment is effective for

management of dissolved gases such as radon, carbon dioxide, some taste and

odor problems such as methane, and hydrogen sulfide, as well as volatile

organic compounds, like MTBE or industrial solvents. It is also effective in

precipitating dissolved iron and manganese. Aeration raises the pH of water.

In the case of iron and manganese, the air causes these minerals to move from

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their dissolved state to a solid state and precipitate out of solution. The water

can then move through a filter to trap the iron and manganese particles.

Aeration devices range from a simple, open holding tank that allows dissolved

gases to diffuse into the atmosphere to a more complex aeration system that

has a column or tower filled with packing material. As water passes through the

packing material, the gases are released.

2.) Coagulation / Flocculation

Coagulation is adding liquid aluminum sulfate or alum and/or polymer to

water. The resulting mixture causes the dirt particles in the water to coagulate

or stick together. Then, the groups of dirt particles attach together, forming

larger particles named flocs that can easily be removed via filtration or settling.

3.) Sedimentation

water and flocs formed as a result of coagulation go into sedimentation basins.

Here, water moves slowly, making the heavy floc particles settle to the bottom.

Floc that accumulates on the bottom is known as sludge. This (sludge) is carried

on to drying lagoons. Direct Filtration does not include the sedimentation step

and the floc is just removed by filtration.

4.) Filtration

In filtration, water passes through a filter, which is made to take away particles

from the water. Such filters are composed of gravel and sand or sometimes

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crushed anthracite. Filtration gathers together impurities that float on water as

well as floc and boosts the effectiveness of disinfection. Filters are regularly

cleaned by means of backwashing.

5.) Disinfection/Chlorination

Before water goes into the distribution system, it is disinfected to get rid of

disease causing bacteria, parasites and viruses. Chlorine is also applied since it

is very effective in disinfection of water.

6.) Sludge Drying

Solids that have been gathered and removed from water via sedimentation and

filtration are called sludge. They are transferred to drying lagoons.

7.) Fluoridation

Fluoridation treats water supplies of communities to adjust the concentration

of free fluoride ions to an optimal level so that dental cavities can be reduced.

8.) PH Correction

To adjust pH levels, lime is combined with filtered water. This, also, stabilizes

naturally soft water so corrosion can be minimized in the water distribution

system and plumbing of customers.

WATER DISTRIBUTION SYSTEM

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Water distribution systems consist of an interconnected series of components.

They include: pipes, storage facilities, components that convey drinking water

to Cities, Homes, Schools, Hospitals, Businesses, Industries and other facilities

REFUSE DISPOSABLE

What is refuse?

Refuse refers to any disposable materials, which includes both recyclable and

non-recyclable materials. This term is often interchangeably with waste, but

refuse is a broad, overarching term that applies to anything that is leftover after

it is used, while waste only refers to leftovers that cannot be recycled.

REFUSE MANAGEMENT

Refuses are manage or treated as follows:-

1. Preventing or reducing waste generation:

Extensive use of new or unnecessary products is the root cause of unchecked

waste formation. The rapid population growth makes it imperative to use

second hand products or judiciously use the existing ones because if not, there

is a potential risk of people succumbing to the ill effects of toxic wastes.

Disposing of the wastes will also assume formidable shape. A conscious

decision should be made at the personal and professional level to judiciously

curb the menacing growth of wastes. So, product with less waste should be

produced.

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2. Recycling:

Recycling serves to transform the wastes into products of their own genre

through industrial processing. Paper, glass, aluminum, and plastics are

commonly recycled. It is environmentally friendly to reuse the wastes instead

of adding them to nature. However, processing technologies are pretty

expensive.

3. Incineration:

Incineration features combustion of refuse to transform them into base

components, with the generated heat being trapped for deriving energy.

Assorted gases and inert ash are common by-products. Pollution is caused by

varied degrees dependent on nature of waste combusted and incinerator

design. Use of filters can check pollution. It is rather inexpensive to burn wastes

and the waste volume is reduced by about 90%. The nutrient rich ash derived

out of burning organic wastes can facilitate hydroponic solutions. Hazardous

and toxic wastes can be easily be rid of by using this method. The energy

extracted can be used for cooking, heating, and supplying power to turbines.

However, strict vigilance and due diligence should be exercised to check the

accidental leakage of micro level contaminants, such as dioxins from incinerator

lines.

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4. Composting:

It involves decomposition of organic refuse by microbes by allowing the waste

to stay accumulated in a pit for a long period of time. The nutrient rich compost

can be used as plant manure. However, the process is slow and consumes a

significant amount of land. Biological reprocessing tremendously improves the

fertility of the soil.

5. Sanitary Landfill:

This involves the dumping of refuse into a landfill. The base is prepared of a

protective lining, which serves as a barrier between wastes and ground water,

and prevents the separation of toxic chemicals into the water zone. Waste

layers are subjected to compaction and subsequently coated with an earth

layer. Soil that is non-porous is preferred to mitigate the vulnerability of

accidental leakage of toxic chemicals. Landfills should be created in places with

low groundwater level and far from sources of flooding. However, a sufficient

number of skilled manpower is required to maintain sanitary landfills.

6. Disposal in ocean/sea:

Wastes generally of radioactive nature are dumped in the oceans far from

active human habitats. However, environmentalists are challenging this

method, as such an action is believed to spell doom for aquatic life by depriving

the ocean waters of its inherent nutrients.

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7. Open burning

EXCRETA DISPOSAL.

Safe disposal of excreta, so that it does not contaminate the environment,

water, food or hands, is essential for ensuring a healthy environment and for

protecting personal health. This can be accomplished in many ways, some

requiring water, others requiring little or none. Regardless of method, the safe

disposal of human faeces is one of the principal ways of breaking the faecal–

oral disease transmission cycle. Sanitation is therefore a critical barrier to

disease transmission.

TECHNOLOGIES FOR EXCRETA DISPOSAL

Technologies for excreta disposal are briefly discussed below:-

Cartage

This is the most basic form of excreta disposal. Faeces are collected in a

container and disposed of daily. An example is the bucket latrine, in which

household wastes are collected in buckets under a hole in the floor of a specific

room. Each day, the bucket is emptied by disposing it directly or into a larger

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container and the contents disposed of. Bucket latrines should not be

promoted because they pose health risks to both users and collectors and may

spread disease. If cartage is considered for your community, a vault latrine (a

latrine where wastes are stored in a sealed container) that is mechanically

emptied on a regular basis is a better choice.

Pit latrines

In most pit latrine systems, faecal matter is stored in a pit and left to

decompose. Unless specifically designed, pit latrines do not require periodic

emptying; once a pit is full it is sealed and a new pit dug. If faecal matter is left

to decompose in dry conditions for at least two years, the contents can be

safely emptied manually and the pit reused. Indeed, some pit latrines are

designed to allow faecal matter to compost and be reused in agriculture. Some

designs use two alternating pits, reducing the need for new pits. Ventilation to

remove odours and flies is incorporated into certain designs, while others are

very basic and use traditional materials and approaches. As with all sanitation

designs, it is important to know what community members want and can pay

for before embarking on construction.

Sanplat

The sanplat is the cheapest and most basic pit latrine. It is a small concrete

platform (usually 60 cm by 60 cm or smaller), laid on top of logs or other

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supporting material traditionally used to cover the pit. The purpose of the

sanplat is to provide a sanitary (san) platform (plat) which can be easily cleaned

to limit the presence of helminths such as hookworm.

Once the pit is full, the sanplat can easily be moved. However, the sanplat

design does not overcome problems with odours or flies and may not be

acceptable to some community members. The sanplat is best used when there

is very little money for improving sanitation and where odours and flies will be

tolerated.

The VIP latrine

The VIP (ventilated improved pit) latrine is designed to overcome some of the

problems with traditional pit latrine designs, but it is more expensive than a

sanplat. It has a vent pipe from the pit to above the roof of the building. When

air flows across the top of the vent pipe, air is drawn up the pipe from the pit

and fresh air is drawn into the pit. Offensive odours from the pit thus pass

through the vent pipe and do not enter the building.

The location of VIP latrines is important unless a clear flow of air is maintained

across the top of the vent if not the ventilation system may not be effective. VIP

latrines should therefore be located away from trees or high buildings that may

limit airflow. A dark vent pipe also helps the air to rise. The top of the dark pipe

is usually covered with fly screen. If the inside of the building is kept partially

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dark, the flies will be attracted to light at the top of the pipe, where they will be

trapped and die. When the VIP latrine is constructed and used properly, it

provides great improvements in fly and odour control, but may not eliminate

either completely.A VIP latrine is designed to work as a dry system, with any

liquid in the content infiltrating into the surrounding soil. Although some liquid

inevitably will enter the pit, it should be minimized. For example, it would not

be appropriate to dispose of household wastewater into the pit as this may

prevent decomposition of the contents. VIP latrines are most appropriate

where people do not use water for cleaning themselves after defecating, but

use solid materials such as paper, corncobs or leaves.

VIP latrines may be designed with single or double pits. The pit of a VIP latrine

is usually located directly beneath the slab to prevent fouling of the chute,

which would lead to odour and fly problems, and require regular cleaning.

Pour–flush latrines

A pour–flush latrine is a type of pit latrine where small volumes of water

(commonly 1–3 litres) are used to flush faeces into the pit. They are most

appropriate where people use water to clean themselves after defecating and

where people have access to reliable water supplies close to the home. Solid

materials should not be disposed of into pour–flush latrines, as this could block

the pipe and even cause it to break.A pour–flush latrine has a small collection

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pan set in a slab. Wastes are disposed of through a section of pipe bent into a U

shape (a U-bend) to maintain a water seal for reducing fly and odour problems.

A vent pipe may also bebadded to the pit to help with fly and odour problems.

The pit of a pour–flush latrine may be located directly beneath the slab or set

to one side, but offset pits may require more water to prevent blockages. The

pit is usually connected to a soakaway to allow liquids to infiltrate the soil,

leaving solid waste to decompose. Pour–flush latrines can also be designed to

be connected to small bore sewers at a later date. As with VIP latrines, twin pits

may be used.

Flush Toilet

A flush toilet also known as a flushing toilet, water closet (WC) is a toilet that

disposes of human excreta (urine and feces) by using water to flush it through a

drain-pipe to another location for disposal, thus maintaining a separation

between humans and their excreta. Flush toilets can be designed for sitting or

for squatting. Flush toilets are a type of plumbing fixture and usually

incorporate an "S", "U", "J", or "P" shaped bend called a trap that causes water

to collect in the toilet bowl to hold the waste and act as a seal against noxious

gases. A typical flush toilet is a fixed, vitreous ceramic bowl (also known as a

pan) which is connected to a drain. After use, the bowl is emptied and cleaned

by the rapid flow of water into the bowl. This flush may flow from a dedicated

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tank (cistern), a high-pressure water pipe controlled by a flush valve, or by

manually pouring water into the bowl. Tanks and valves are normally operated

by the user, by pressing a button, pushing down on a handle, pulling a lever or

pulling a chain. The water is directed around the bowl by a molded flushing rim

around the top of the bowl or by one or more jets, so that the entire internal

surface of the bowl is rinsed with water.

Most flush toilets are connected to a sewerage system that conveys waste to a

sewage treatment plant; where this is not available, a soakaway or a septic tank

may be used. When a toilet is flushed, the wastewater flows into a soakaway, a

septic tank, or is conveyed to a treatment plant.

Septic tank

A septic tank is an underwater sedimentation tank used for waste water

treatment through the process of biological decomposition and drainage.

A septic tank makes use of natural processes and proven technology to treat

wastewater from household plumbing produced by bathrooms, kitchen drains

and laundry.

Septic tanks are designed to collect sewage and wastewater from households

that are not connected to the mains sewer. There are two main types of septic

tank applications: Septic tank with a soakaway and septic tank with out

soakaway.

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The Step-by-step Process of How a Septic Tank Works

 Water from your kitchen, bathroom etc runs through one main drainage

pipe leading to your septic tank.

 Underground the septic tank starts the process of holding the waste

water. It needs to hold this long enough so the solids ( sludges) settle

down to the bottom, while oil and grease floats to the top.

 After this process the liquid wastewater (effluent) will then be able to

exit the tank into the drain field.

 This wastewater is discharged through pipes onto porous surfaces. These

allow wastewater to filter though the soil. The soil accepts, treats, and

disperses wastewater as it percolates through the soil, ultimately

discharging to groundwater.

 Finally, the wastewater percolates into the soil, naturally removing

harmful coliform bacteria, viruses and nutrients.

SEWERAGE SYSTEMS

Sewerage systems are designed to collect excreta and domestic wastewater

and transport them away from homes to a treatment and/or disposal point.All

sewerage systems require water for flushing waste away. Conventional

sewerage is a high-cost sanitation option; it is usually deep-laid and must be

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maintained by professional staff. Such a system is thus appropriate only where

funds are available for operation and maintenance by trained staff. All

sewerage systems should be linked to a treatment plant, as the raw faeces they

carry represent a public health riskModified sewerage systems are also

designed to transport waste away from the home, but work on different

principles from conventional sewerage systems. They do not require high-

volume flush toilets, but do need significant amounts of water for flushing. At

least one tap on each plot or property is therefore essential.

Small bore sewers are designed to carry only effluent, and each home requires

an interceptor tank to collect and store solid material, which must be regularly

emptied by mechanical means.Shallow sewers are larger-diameter sewers that

carry both solid and liquid wastes. They differ from conventional sewers in that

solids deposited in the pipes are resuspended when water builds up behind the

blockage. To ensure that enough water is available to move the solids, all

household wastewater should be disposed of into the sewer. While both of

these modified sewerage systems have problems, they have been successfully

managed by communities and have far lower water requirements than

conventional sewers. The modified technologies may be appropriate in larger

villages that have water supplies close to, or within, the homes.

Sewage treatment and reuse

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All wastes in sewerage or septic tank systems require treatment before

disposal, so that surface water and groundwater sources are not contaminated

and communities are not exposed to health risks from untreated sewage. This

can be accomplished either through high-cost conventional treatment systems,

or through a series of waste stabilization ponds (or lagoons).

Waste Stabilization Ponds

Waste stabilization ponds require more land, but are cheaper and easier to

operate and maintain, and need fewer trained staff than other treatment

systems. The final water from waste stabilization ponds can be very good if the

ponds are properly maintained. Without proper maintenance, however, the

quality of the final effluent may be poor and pose a risk to health even if it is

used for irrigation.In usual configurations, sewage flows through a series of

ponds where the solid and liquid wastes undergo natural breakdown processes,

including microbial activity. Usually, at least two ponds are used, and more

commonly three. If the sludge (the solid part of the waste) from septic tanks is

to be treated in a waste stabilization pond, it should go into a special pond at

the start of the series because it is potentially highly toxic. Subsequent ponds

treat effluent (the liquid part of the waste). Wastewater in stabilization ponds

tends to have a high organic content and can serve as breeding sites for Culex

mosquitoes that transmit lymphatic filariasis and other infections. The ponds

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should therefore be sited well away from human habitation, at least beyond

the flying distance of the mosquitoes (over a kilometre with wind assistance).

Wastewater and sludge reuse

As society uses more water, the demand on natural water resources

becomesever greater. Some of the demands for water, particularly for

agriculture and fish breeding, can be met by reusing properly treated effluent,

since the water quality requirements for these purposes are not as high as for

drinking-water.Treated wastewater can also be used to recharge groundwater

resources, although this will be usually be undertaken as part of a national

ground water management strategy. The sludge are also used for agricultural

purpose after treatment

HEALTH CARE WASTE MANAGEMENT

Waste generated by health care activities includes a broad range of materials,

from used needles and syringes to soiled dressings, body parts, diagnostic

samples, blood, chemicals, pharmaceuticals, medical devices and radioactive

materials. Poor management of health care waste potentially exposes health

care workers, waste handlers, patients and the community at large to infection,

toxic effects and injuries, and risks polluting the environment. It is essential that

all medical waste materials are segregated at the point of generation,

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appropriately treated and disposed of safely. Healthcare waste (HCW) is a by-

product of healthcare that includes sharps, non-sharps, blood, body parts,

chemicals, pharmaceuticals, medical devices and radioactive materials.

DEFINITION OF MEDICAL WASTE

Medical waste is any kind of waste that contains infectious material (or

material that’s potentially infectious). This includes waste generated by

healthcare facilities like physician’s offices, hospitals, dental practices,

laboratories, medical research facilities, and veterinary clinics.

It is also defines as waste generated during medical research, testing,

diagnosis, immunization, or treatment of either human beings or animals. Some

examples are culture dishes, glassware, bandages, gloves, discarded sharps like

needles or scalpels, swabs, and tissue etc.

TYPES OF MEDICAL WASTE

Medical Waste and by-products cover a diverse range of materials. They

include:

1.) General Medical Waste:

General medical waste shares large portion in healthcare waste. They are non-

hazardous in nature. General waste includes paper, plastic, and office wastes.

These can be disposed of regularly and don’t require any special handling.

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2.) Infectious waste:

Waste contaminated with blood and body fluids and its by-products, cultures

and stocks of infectious agents, waste from patients in isolation wards,

discarded diagnostic samples containing blood and body fluids, infected

animals from laboratories, and contaminated materials (swabs, bandages) and

equipment (such as disposable medical devices); are considered as infectious

waste. All wastes that are susceptible to contain pathogens (or their toxins) in

sufficient concentration to cause diseases to a potential host. Examples of

infectious waste include discarded materials or equipment used for the

diagnosis, treatment and prevention of disease that has been in contact with

body fluids (dressings, swabs, nappies, blood bags). This category also includes

liquid waste such as faeces, urine, blood or other body secretions (such as

sputum or lung secretions). Waste from autopsies and infected animals from

laboratories), or waste from patients with infections (e.g. swabs, bandages and

disposable medical devices);

3.) Sharps waste: syringes, needles, disposable scalpels and blades, etc.;

4.) Chemical waste: for example solvents and reagents used for laboratory

preparations, disinfectants, sterilants and heavy metals contained in medical

devices (e.g. mercury in broken thermometers) and batteries;

5.) Pathological waste:

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This are recognizable human body parts and contaminated animal carcasses;

Pathological waste consists of organs, tissues, body parts or fluids such as

blood. Even if pathological waste may contain healthy body parts, it has to be

considered as infectious waste for precautionary reasons.

6.) Anatomical waste

This is a sub-group of pathological waste and consists in recognisable human

body parts, whether they may be infected or not. Following the precautionary

principles, anatomical waste is always considered as potential infectious waste.

7.) Pharmaceutical wastes:

Expired, unused, and contaminated drugs; vaccines and sera; Pharmaceutical

waste includes expired, unused, spilt and contaminated pharmaceutical

products, drugs and vaccines. In this category are also included discarded items

used in the handling of pharmaceuticals like bottles, vials, connecting tubing.

Since various ministries of health or their equivalents usually put in place

specific measures that will reduce the the wastage of drugs, Health care

facilities should deal only with small quantities of pharmaceutical wastes. This

category also includes all the drugs and equipment used for the mixing and

administration of cytotoxic drugs. Cytotoxic drugs or genotoxic drugs are drugs

that have the ability to reduce/stop the growth of certain living cells and are

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used in chemotherapy for cancer. Cytotoxic waste is dealt with under a

separate heading.

8.) Genotoxic waste or cytotoxic waste

Highly hazardous, mutagenic, teratogenic or carcinogenic, such as cytotoxic

drugs used in cancer treatment and their metabolites; Genotoxic waste derives

from drugs generally used in oncology or radiotherapy units that have a high

hazardous mutagenic or cytotoxic effect. Faeces, vomit or urine from patients

treated with cytotoxic drugs or chemicals should be considered as genotoxic. In

specialised cancer hospitals, their proper treatment or disposal raises serious

safety problems.

9.) Radioactive waste:

These are wastes such as glassware contaminated with radioactive diagnostic

material or radiotherapeutic materials; Radioactive waste includes liquids, gas

and solids contaminated with radionuclides whose ionizing radiations have

genotoxic effects (i.eHighly hazardous, mutagenic, teratogenic or carcinogenic).

The ionizing radiations of interest in medicine include X- and g-rays as well as a-

and b- particles. An important difference between these types of radiations is

that X-rays are emitted from X-ray tubes only when generating equipment is

switched on whereas g-rays, α- and β- particles emit radiations continuously.

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10.) Laboratory waste:

This is also high risk category waste. This includes chemicals used in the

pathological laboratory, microbial cultures and clinical specimens, slide, culture

dish, needle, syringes, as well as radioactive waste such as Iodine-125, iodine -

131.

Note:- Infectious and anatomic wastes together represent the majority of the

hazardous waste, up to 15% of the total waste from health-care activities.

Sharps represent about 1% of the total waste but they are a major source of

disease transmission if not properly managed. Chemicals and pharmaceuticals

account for about 3% of waste from health-care activities while genotoxic

waste, radioactive matter and heavy metal content account for around 1% of

the total health-care waste.

THE MAJOR SOURCES OF HEALTH-CARE WASTE ARE:

 Hospitals and other health-care establishments

 Laboratories and Research centres

 Mortuary and Autopsy centres

 Animal research and testing laboratories

 Blood banks and Collection services.

 Nursing homes for the elderly

 Clinics

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METHOD OF MEDICAL WASTE DISPOSAL

This is divided basically into two:-

(1) On-Site Medical Waste Treatment:

This includes:-

 Autoclaving

 Chemical Treatment

 Microwave Treatment

(2) Off-Site Medical Waste Disposal

This includes:-

 Incineration

 Land Disposal

 Encapsulation

 Inertization

 Biological

Detail explanations of each are given below:-

2.) Chemical disinfection/treatment:

Chemical disinfection is used to kill microorganisms on medical equipment,

floors and walls. It is also used to the treat the health-care waste. Chemicals are

added to waste to kill or inactivate the pathogens. This method is appropriate

for treating liquid waste such as blood, urine, stools, or hospital sewage.

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However, other waste can also be disinfected using chemical disinfection

before disposal. Some kinds of chemical waste may also be neutralized by

applying reactive chemicals that render it inert. Anatomical parts, animal

carcasses are usually not disinfected.

3.) Autoclaving:

Autoclaving is an efficient waste thermal disinfection process which is done

using an autoclave. Autoclaving is the processes of treatment in pressurized

condition. An autoclave is used to sterilize reusable medical equipment like

surgical equipment, laboratory instruments, pharmaceutical items, and other

materials. This method can be used to sterilize solids, liquids, hollows, and

instruments of various shapes and sizes rendering the biohazardous waste non-

infectious. After it’s been sterilized, the waste can be disposed of normally in

solid waste landfills, or it can be incinerated under less-stringent regulation.

4.) Encapsulation:

In this process, cubic boxes made of high-density polyethylene or metallic

drums, are filled with are sharps and chemical or pharmaceutical wastes. These

cubic boxes are not completely filled. The remaining portion is covered with

cement or mortar, dried and sealed before disposal. Encapsulation is very

effective in reducing the risk of scavengers or stray animals gaining access to

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the hazardous health-care waste. Encapsulation is not suitable for non-sharp

infectious waste, but may be used in combination with burning of such waste.

5.) Inertization:

Inertization is the process of mixing waste with cement and other substances

before disposal. This reduces the chance of mixing of toxic substances

contained in the waste to surface water or groundwater. Suitable for

pharmaceuticals and for incineration ashes with a high metal. The typical

proportions for the mixture is: 65% pharmaceutical waste, 15% lime, 15%

cement and 5% water. Inertization however is expensive and not suitable for

wider variety of waste

6.) Land disposal:

Land disposal is the way of disposal of waste rather than its treatment. There

are two distinct types of waste disposal to land; open dumps and sanitary

landfills.

Open dumps are unmanaged and waste are scattered as well. The risk of the

further transmission of the infection or disease is high.

Sanitary landfills are scientific and designed for the disposal of hazardous

waste. Sanitary landfill prevents contamination of soil and of surface water and

groundwater. Sanitary landfill also checks the air pollution and contact with the

public. Wastes are treated before disposal and managed on daily basis.

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7.) Microwaving

Another way to render hazardous healthcare waste non-hazardous is to

microwave it with high-powered equipment. As with autoclaving, this method

opens up the waste to normal landfill disposal or incineration afterward.

8.) Biological.

This experimental method of treating biomedical waste uses enzymes to

neutralize hazardous, infectious organisms. It’s still under development and

rarely used in practice.

MEDICAL WASTE DISPOSAL COLOR CODE.

The color coding system for waste segregation calls for all:

Sharps to go in puncture resistant red biohazard containers. Biohazard waste

goes in red bags and containers.

Yellow containers are for trace chemo waste, while pharmaceutical waste goes

into black containers and blue container for all others wastes. Radioactive

wastes like Fluorine-18 or Iodine-131 get put in shielded containers marked

with the radioactive symbol.

REASONS FOR FAILURE OF WASTE MANAGEMENT

 Lack of awareness about the health hazards related to health-care waste.

 Inadequate training in proper waste management.

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  Absence of waste management and disposal systems.

 Insufficient financial and human resources and the low priority given.

 Lack of appropriate regulations, or enforce waste management.

 Lack of clear attribution of responsibility for the handling and disposal of

waste. According to the 'polluter pays' principle, the responsibility lies

with the waste producer, usually the health-care provider, or the

establishment involved in related activities.

PRINCIPLES OF HEALTH CARE WASTE MANAGEMENT

1. Duty of care principle

This principle stipulates that any organisation that generates waste has a duty

to dispose of the waste safely. Therefore it is the Health Care Facility (HCF) that

has ultimate responsibility for how waste is containerized, handled on-site and

off-site and finally disposed of.

2. Polluter pays principle

According to this principle all waste producers are legally and financially

responsible for the safe handling and environmentally sound disposal of the

waste they produce. In case of an accidental pollution, the organisation is liable

for the costs of cleaning it up. Therefore if pollution results from poor

management of health-care waste then the Health Care Facility is responsible.

However, if the pollution results because of poor standards at the treatment

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facility then the Health Care Facility is likely to be held jointly accountable for

the pollution with the treatment facility. Likewise this could happen with the

service provider. The fact that the polluters should pay for the costs they

impose on the environment is seen as an efficient incentive to produce less and

segregate well.

3. Precautionary principle

Following this principle one must always assume that waste is hazardous until

shown to be safe. This means that where it is unknown what the hazard may

be, it is important to take all the necessary precautions.

4. Proximity principle

This principle recommends that treatment and disposal of hazardous waste

take place at the closest possible location to its source in order to minimize the

risks involved in its transport. According to a similar principle, any community

should recycle or dispose of the waste it produces, inside its own territorial

limits.

FIVE FUNDAMENTAL PRINCIPLES FOR HANDLING HEALTH CARE WASTES

These principles include:-

o Minimization and Recycling.

o Sorting receptacles and handling.

o Collection and Storage.

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 o Transportation, and

o Treatment and Disposal .

1.) Minimization and recycling

The reduction of waste generation must be encouraged by the following

practices: Reducing the amount of waste at source, Choosing products that

generate less waste: less wrapping material, for example, Choosing suppliers

who take back empty containers for refilling (cleaning products); returning gas

cylinders to the supplier for refilling, Preventing wastage: in the course of care,

for example, or of cleaning activities, Choosing equipment that can be reused

such as tableware that can be washed rather than disposable tableware.

2.) Sorting receptacles and handling

Sorting consists of clearly identifying the various types of waste and how they

can be collected separately. There are two important principles that must be

followed. The simplest way to identify the different types of waste and to

encourage people to sort them is to collect the various types of waste in

separate containers or plastic bags that are colour-coded and/or marked with a

symbol. Waste sorting must always be the responsibility of the entity that

produces them. It must be done as close as possible to the site where the

wastes are produced. There is no point in sorting wastes that undergo the same

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treatment process, with the exception of sharps, which must at all times be

separated at source from other wastes.

3.) Collection and storage

Waste must be collected regularly at least once a day. It must never be allowed

to accumulate where it is produced. A daily collection programme and

collection round must be planned. Each type of waste must be collected and

stored separately with different known signs on the containers.

Infectious wastes must never be stored in places that are open to the public.

The personnel in charge of collecting and transporting wastes must be

informed to collect only those yellow bags and sharps containers which the

care staff have closed. They must wear gloves. The bags that have been

collected must be replaced immediately with new bags.

4.) Transportation

This means of conveyance must meet the following requirements: they must be

easy to load and unload; they must not have any sharp corners or edges that

might tear the bags or damage the containers; they must be easy to clean;

(with a 5% active chlorine solution); they must be clearly marked.

Furthermore, off-site means of transport must meet the following

requirements:-

 They must be closed in order to avoid any spilling on the road;

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  They must be equipped with a safe loading system (to prevent any

spilling inside or outside the vehicle);

 They must be marked according to the legislation if the load exceeds 333

kg (for some countries).

 The entity producing the waste is responsible for packaging and labelling

the waste to be transported outside the hospital.

 Packaging and labelling must be in conformity with national legislation on

the transport of dangerous substances and with the Basel Convention in

the case of cross-border transport.

 If there is no national legislation on the subject, the United Nations

recommendations on the Transport of Dangerous Goods or the European

Agreement on the International Carriage of Dangerous Golds by Road

(ADR) 1413 should be referred to.

5.) Treatment and disposal

Choices of treatment and disposal technique depend on a number of

parameters. These include the quantity and type of waste produced, availability

of waste treatment site near the waste generating facility, availability of

reliable means of transport, availability of National legislation on health care

waste management, climate conditions, groundwater level, regular supply of

electricity in the area etc. The handling and treatment of waste entails health

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risks for staff throughout the chain. The purpose of protective measures is

seriously recommended to reduce the risks of accident/exposure or the

consequences.

DISINFECTION AND TREATMENT OF LIQUID WASTE

 Infectious liquid waste generated from the hospital like blood, body

fluids, secretions, discarded samples etc. needs to be disinfected by the

use of 1%-2% hypochlorite solution with a minimum contact time of 30

minutes before final disposal.

 Housekeeping material used in the hospital needs to be diluted with

ample amount of water before discharging the same into municipal

drains.

 Disinfectants and laboratory reagents used in the hospital need to be

treated and disposed of as per the manufacturer’s guidelines.

 All the liquid waste generated from the hospital needs to be

appropriately treated in-house before disposing off the same into the

municipal drains.

 It is recommended that District Hospital level facilities should treat the

liquid waste generated through dedicated Effluent Treatment System if

sewage treatment facilities are not provided by municipal agencies. For

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smaller facilities such as CHC and PHC onsite disinfection of liquid waste

can be done through local Liquid Waste Disinfection set-up

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