K. Park 26th edition - New updates.pdf

K park community health nursing textbook.

1. Park'sTextbookof
PREVENTVE
ANDSOCIAL
MEDICINE
K.PARK
***
(50
*****
(26
70-202
ED
EANCT T1O

2. CONTENTS
Page
Chapter
MANANDMEDICINE TOWARDSHEALTHFORALL
13
*
2.
CONCEPTOFHEALTHANDDISEASE
60
3.PRINCIPLESOFEPIDEMIOLOGY ANDEPIDEMIOLOGICMETHODS
100
Infectiousdiseaseepidemiology.
Diseasetransmission.
*********
AimsofEpidemiclogy
Epidemiologicalapproach...
Measurementofmortality
.
Ratesandratios
Measurementofmorbidity*********
102
.109
Immunity
.111
immunisingagents
Coldchain
****** ***** **
************"
65
** ******* ********* **********
.117
I20
122
OpenVialPblicy
..
Adverseeventsafterimmunization.
Diseasepreventionandcontrol.....
70Epidemiclogicmethods..
Descriptiveepidemiclogy.
Analyticalepidemiologs
Cohertstudy.
130
Immunicationschedule.. 134
Disinfection..
Investigationofanepidemic
139
.146
SSExperimentaepidemiology.
Associationandcausation...95
Usesofepidemiology 99
*****
150
4.SCREENINGFORDISEASE
Coneeptofscreening.. 150 Sensitivityandspeciñicity..
Usesofscreening.
151 Problemsoftheborderline...
Criteriaforscreening.
15S
EPIDEMIOLOGY OFCOMMUNICABLE DISEASES
***
***
I.Respiratoryinfections
Whoopingcough
..
Meningococcalmeningitis.
**79
181
183
158Smallpox.
Chickenpox. 158
Acuterespiratoryiniections
SARS.
COVID-19.
Measles 161
Rubella
5 190
Mumps 192
********n
Ib8
169Influenza. Tuberculosis 204
Diphtheria 175
I.Intestinalinfections
Foodpoisoning.
****************************************276
Poliomyelitis
Viralhepatitis
Acutediarrhoealdiseases.
Cholera
Typhoidfever.
236*********
244 Amoebiasis. *278S
258 Ascariasis
Hookworminfection
Dracunculiasis..
266 281
272 283
l.Arthropod-borneinfections
LymphaticFilariasis...
ZikaVirusDisease.
Denguesyndrome.HiEaastaoaisdasiss284 ..310
Malariai 294 16
IVZoonoses
Viral
Rabies.
Yellowfever
Bacterial
Chikungunyafever.317
322 Brucellosis.
332
Nipahvirusinfection
Japaneseencephalitis 26
KFD
** dZ5, Leptospirosis..
334
330 Humansaimonellosis....
40)
***********+tsasA++a

3. Porasitic
z0ottose2s
Taeniasis
Hydatid
disease.
Leishmaniasís
.345Rirkettsidldiseases
v*d************** **vii
341
346
Ricketsinl
ztoconoses
Scrubtvphus.
Musinelyphus....
Ticktyphus
342
342
343
V.Surface
infections
STDosnee
**************************************veus374
35
351
niiietivrë*
******v************************oiz
Trachorma..
i.disssatecas
Telanus
1444aniiiintes**i
.37
,353
AIDSo
357 400
Leprosy.
VI.Emergingand
re-emerging
infectiousdiseases
404
VII.Hospital
acqufred
Infections
407* ****
EPIDEMIOLOGYOF
CHRONIC
NON-COMMUNICABLE
DISEASESAND
CONDITIONS
******
6.
438
Diabetes.r*
******************************************
Cardiovasculardiseases..
.
411
Coronaryheartdisease...
412
Hypertension..
.ausnasan419
Obesity 43
Blindness..
Oraldiseases..
*********************w************-***v,
AccidentsandInjuries..
***************w******
Rheumatichearldisease..425
Cancer.***********is******
..427
464****
7.
HEALTHPROGRAMMES ININDIA
540
*********
***
8.ESSENTIALMEDICINESANDcOUNTERFEITMEDICINES
552*****
***
9
MILLENNIUMDEVELOPMENT GOALSTO
SUSTAINABLEDEVELOPMENT GOALS
560
**
*********
10.DEMOGRAPHY ANDFAMILYPLANNING
602
********
11.PREVENTIVEMEDICINEINOBSTETRICS,
PAEDIATRICSANDGERIATRICS
698
.4
********
12.NUTRITIONANDHEALTH
158
*****
13.MEDICINEANDSOCIALSCIENCES
795
14.TRIBALHEALTHININDIA
79
15.ENVIRONMENT ANDHEALTH
**
***
833
16.HOSPITALWASTEMANAGEMENT ***
**
88
17.DISASTERMANAGEMENT
89E
18.ocCUPATIONALHEALTH
915
19.GENETICSANDHEALTH
******
20.MENTAL,HEALTH
925
21.HEALTHINFORMATIONANDBASICMEDICALSTATISTICCS
93-
*** ***
22
COMMUNICATION FORHEALTHEDUCATION
23.HEALTHPLANNINGANDMANAGEMENT
95
+**
96
***
***
24.
HEALTHCAREOFTHECOMMUNITY
25.
INTERNATIONAL HEALTH
98
***
101
ABBREVIATIONS
10
INDEX

4. 32
CONCEPTOF
HEALTHAND
DISEASE
Thehealthindexisaweightedcompositeindex,which
is
comes
basedonindicatorsinthreedomains
:
(a)Healthoutco
5.HealthIndexofIndia(NitiAayog)(68)
(70percent);(b}Governanceandinformation(12per
co
and(c)Keyinputsand
processes(18percent).Eachdoma
NitiAayogofIndiarecentlyrankedallstatesand
UTsin
anattempttomeasurethenationshealth
performance.The
statesand
UTsaregroupedinthree
categoriestoensure
comparisonsamongsimilarentitiesnamely21largerstates,
8smallerstatesand
7UnionTerritoriesasshowninTable5.
isassignedaweightbasedonitsimportance.Withinadomain
orsub-domain,theweighthasbeenequallydistribute
amongtheindicators.Table6providesthedetailedheals
indexwithindicators,theirdefinitions,thedatasources
and
TABLE5 specificsofbaseyear(BY)andreferenceyear(RY)(68).
Categorizationofstatesand
UTs
DEVELOPED
ANDDEVELOPINGREGIONS
Number
worldtodayisdividedintodevelopedand
developingregionsonthebasisofsomecommonfeatures
sharedbythem.Theformerisrepresentedbycountriessuch
asUSAand
UK,andthelatterbycountriessuchasIndia.If
onedefineddevelopmentastheorganizationofsocietyto
provideadequatehousing,food,healthservices,education
andemploymentforthemajorityofpeople,thenmany
ofthemark.Socialmedicine
Statesand
UTs
CategoryofStates
and
UTs
The
AndhraPradesh,Assam,Bihar,
Chhattisgarh,Gujarat,Haryana,Himachal
Pradesh,Jammu&Kashmir,Jharkhand,
Karnataka,Kerala,MadhyaPradesh,
Maharashtra,Odisha,Punjab,Rajasthan,
TamilNadu,Telangana,UttarPradesh,
Uttarakhand,WestBengal
21Larger
states
developingcountriesarewid
ArunachalPradesh,Goa,Manipur,
Meghalaya,Mizoram,Nagaland,Sikkim,
Tripura
isconcernedwithdisparitiesthatexistamongcountries.
This
isbecausesocio-economicfactorsandhealthproblemsare
interlinked.Anaccountofthesedisparities
isgivenbelowSmaller
states
Union
Territories
Andaman&Nicobar,Chandigarh,Dadra
&NagarHaveli,Daman&Diu,Delhi,
Lakshadweep,Puducherry
1.Socialandeconomiccharacteristics
Mostpeopleinthedevelopingcountriesliveinruralareas
TABLE6
HealthIndex:Indicators,definitions,baseandreferenceyears
BaseYear(BY)
&Reference
Year(RY)
S.No.Indicator
Definition
DOMAIN1
-
HEALTHOUTCOMES
Sub-domain1.1
-Keyoutcomes(Weight:largerstates
-500,smallerstates&UTs-100)
BY:2015
1.1.1Neonatalmortality
rate(NMR)
Numberofinfantdeathsoflessthan29daysperthousandlivebirths
duringaspecificyear.
RY:2016
Numberofchilddeathsoflessthan5yearsperthousandlivebirths
duringaspecificyear.
BY:2015
1.1.2Under-fivemortality
rate(U5MR)
RY:2016
1.1.3Totalfertility
rate(TFR)
Averagenumberofchildrenthatwouldbeborntoawomanifsheexperiences
thecurrentfertilitypatternthroughoutherreproductivespan(15-49years),
duringaspecificyear.
BY:2015
RY:2016
1.1.4Proportionoflowbirth
weight(LBW)among
Proportionoflowbirthweight(2.5kg)newbornsoutofthetotalnumberof
newbornsweighedduringaspecificyearborninapublichealthfacility.
BY:2015-16
RY:2017-18
newborns
1.1.5Sexratioatbirth(SRB) Thenumberofgirlsbornforevery1,000boysbornduringaspecificyear. BY:2012-15
RY:2014-16
Sub-domain1.2
-Intermediateoutcomes(Weight:larger&smallerstates-300,UTs-250)
Proportionofinfants9-11
monthsoldwhohavereceivedBCG,3doses
ofDPT,3dosesofOPVandonedoseofmeaslesagainstestimatednumber
ofinfantsduringaspecificyear.
1.2.1Fullimmunization BY:
2015-18
RY:2017-18
coveragee
1.2.2Proportionof
institutionaldeliveries
Proportionofdeliveriesconductedinpublicandprivatehealthfacilities
againstthenumberofestimateddeliveriesduringaspecificyear.
BY:2015-16
RY:2017-18
Totalcasenotification
rateoftuberculosis(TB)
1.2.3
NumberofnewandrelapsedTBcasesnotified(public+private)
per100,000populationduringaspecificyear.
By:2016
RY:2017
1.2.4Treatmentsuccessrate
ofnewmicrobiologically
confirmedTBcases
Proportionofnewcuredandtheirtreatmentcompletedagainstthetotal
numberofnewmicrobiologicallyconfirmedTBcasesregistered
duringaspecificyear.
BY:
2015
RY:2016
1.2.5Proportionofpeople
livingwithHIV(PLHIV)
onantiretroviral
therapy(ART)
ProportionofPLHIVsreceivingARTtreatmentagainstthenumberof
estimatedPLHIVswhoneededARTtreatmentforthespecificyear.
BY:2015-16
RY:2017-18

5. 33VETO/) ANDEUEIFINGPEGON
BaseYear(BY)
&Reference
Year(RY}
S.No.Indicator Definition
DOMAIN2GOVERNANCE ANDINFORMATION
Sub-domiain2,1healthmonitoringanddataintegrity(Weight:70)
2.1.1DataIntegrityMeasure
:
a.Institutionaldeliveries
b.ANCregisteredwithin
firsttrimester
BY&RY
2015-16(NFHS)
BY&RY:2011-12
ta2015-2016
(HMIS)
Percentagedeviationofreporteddatafromstandardsurveydatato
assessthequality/integrityofreporteddataforaspecificperiod.
Sub-domain2.2
-Governance(Weight-60)
2.2.1Averageoccupancyofan
officer(inmonths),
combinedforfollowing
threepostsatstatelevel
forlastthreeyears
1.PrincipalSecretary
2.MissionDirector(NHM)
3.Director(HealthServices)
Averageoccupancy
ofanofficer(inmonths),combinedforfollowingpostsinBY:April1,2013-
March31.2016lastthreeyears:
1.PrincipalSecretary
2.MissionDirector(NHM)
3.Director(HealthServices) RY:April1,2015-
March31.2018
2.2.2Averageoccupancy
ofa AverageoccupancyofaCMO(inmonths)forallthedistricts
inlastthreeyears.
BYApril1.2013-
March31.2016full-timeofficer(inmonths)
forallthedistrictsinlast
threeyears
-DistrictChief
MedicalOfficers(CM0s)
orequivalentpost
(headingDistrictHealth
Services)
RYApril1,2015-
March31,2018
DOMAIN3-KEYINPUTS/PROCESSES
Sub-domain3.1
-healthsystems/servicedelivery(Weight-200)
3.1.1Proportionofvacant
health-careprovider
positions(regular+
contractual)inpublic
healthfacilities
BY:As
on
March31,2016
Vacanthealth-careproviderpositionsinpublichealthfacilitiesagainsttotal
sanctionedhealth-careproviderpositionsforfollowingcadres(separately
foreachcadre)duringaspecificyear:
a.Auxiliarynursemid-wife(ANM)atsub-centers(SCs)
b.Staffnurse(SN)atPrimaryHealthCenters(PHCs)andCommunity
HealthCenters(CHCs)
c.Medicalofficers(MOs)atPHCs
d.SpecialistsatDistrictHospitals(Medicine,Surgery,Obstetricsand
Gynaecology,Paediatrics,Anaesthesia,Ophthalmology,Radiology.
Pathology,Ear-Nose-Throat(ENT),Dental,Psychiatry)
RY:As
on
March31.2018
BYAson
March31,2016
3.1.2Proportionoftotalstaff
(regular+contractual)
forwhomane-payslip
canbegeneratedinthe
1IT-enabledHuman
ResourcesManagement
System(HRMIS).
AvailabilityofafunctionalIT-enabledHRMISmeasuredbytheproportion
ofstaff(regular+contractual)forwhomane-payslipcanbegenerated
intheIT-enabledHRMISagainsttotalnumberofstaff
(regular+contractual)duringaspecificyear RY:As
on
March3L,2018
Proportionofpublicsectorfacilitiesconductingspecifiednumber
ofC-sections"peryear(FRUs)againstthenormofoneFRU
per500,000populationduringaspecificyear.
BY:2015-163.1.3a.Proportionofspecified
typeoffacilities
functioning
asFirst
Referra!Units(FRUs)
RY:2017-18
BY:2015-16
b.Proportionof
functional24x7PHCs
ProportionofPHCsprovidingallstipulatedhealth-careservices**round
theclockagainstthenormofone24x7PHCper100,000population
duringaspecificyear. RY:2017-18
3.1.4Proportionofdistricts
with
functionalCardiac
CareUnits(CCUs)
ProportionofdistrictswithfunctionalCCUs[withdesiredequipment
(ventilator,monitor,defibrillator,CCUbeds,portableECGmachine,
pulseoxymeteretc.),drugs,diagnosticsanddesiredstaffasper
programmeguidelines)againsttotalnumberofdistricts.
BY:As
aon
March31,2016
RY:As
on
March31,2018
ProportionofpregnantwomenregisteredforANCwithin12weeksof
pregnancyduringaspeciicyear.
BY2015-16315ProportionofANC
registeredwithinfirst
trimesteragainsttotal
registrations
RY:
2017-18

6. 4 CONCEPTOFHAL11ANDD1SEASE
BaseYear
(B
&RelerenceS.No.Indicator Deflinilion
Year(RY)
ProportionofbirthsregisteredunderCivilRegistrationSystem(CRS)
ngainsttheestimalednumberofbirihsduringaspecilicyear.
3.1.6Levelofreglstration
BY
2014
ofbirths
RY
2016
3.1.7CompletenessofIDSP
reportingofPandLioms
ProportionofReportingUnits(RUs)reportinginstipulatedtimeperiod
againsttolalRUs,forPand
Lformsduringaspecificyear.
2015
2017Y
3.18ProportionofCHCswith
gradingabove
3points
ProportionofCHCsthataregradedabove3pointsagainsttotalnumberof
CHCsduringaspecificyear
BY:
2015-16
RY:2017-18
BY:Ason
March31,2016
3.1.9Proportionofpublichealth
facilitieswithaccreditation
certificatesbyaslandard
qualityas5suranceprogram
(NQAS/NABH/ISO/AHPI)
Proportionofspecifiedtypeofpublichealthfacilitieswithaccreditation
certilicatesbyastandardqualityassuranceprogramagainstthetotal
numberfollowingspecifiedtypeoffacilitiesduringaspecificyear.
1.Districthospital(DH)/Sub-districthospital(SDH)
2.CHC/BlockPHC
RY:Ason
March31.2018
BY:2015-16
3.1.10Averagenumberofdays
fortransferofCentral
NHMfundfromState
Averagetimetaken(innumberofdays)bytheStateTreasurytotransfer
fundstoimplemenlationagenciesduringaspecificyear.
RY:2017-18
Treasurytoimplementation
agency(Department/Society)
basedonalltranchesof
thelastfinancialyear
CriteriaforfullyoperationalFRUs:SDHs/CHCsconductingminimum60C-sectionsperyear(36C-sectionsperyearforHillyandNorth.
EasternStatesexceptforAssam);DHs-conductingminimum120C-sectionsperyear(72C-sectionsperyearforHillyandNorth-Eastern
StatesexceptAssam).
**
Criteriaforfunctional24x7PHCs:10deliveriespermonth(5deliveriespermonthforHillyandNorth-EasternStatesexceptAssam)
#CentreNHMFinancedataincludestheRCHflexi-poolandNHM-HealthSystemStrengtheningflexi-pooldata(representingasubstantial
portionoftheNHMfunds)forcalculatingdelayintransferoffunds.
populationgrowthisslowingdownalmosteverywhere
exceptAfrica.Thetertilityrateisnowatorbelow
replacementlevelin44percentofcountriesintheworld
Highfertilityhasmultipleconsequencestorhealth
and
healthrelatedissues.Continuedrapidpopulationgrowthin
lowandlower-middle-incomecountries,alongwithhigher
fertilityratesinpoorestsegmentsotthepopulationmakes
hardertoeradicatepoverty,combathunger
and
malnutrition,investinhealthandeducation,improve
access
tobasicservices,plananddevelopcities,protect
local
ecosystemsandpromotepeacefulsocieties(66).
andurbanslums.Thereisarigidhierarchyandclass
structuremouldedbytraditionandlong-standingcustoms.
Thefamily,oftenajointfamily,
isastrongbindingforce.
Peopledependmainlyonagricultureandthereisalackof
alternativeemploymentopportunities.TheGNPpercapita
rangesfromUS$2000to6000inmostdeveloping
countrie5.Theproductionandconsumptionpercapita
are
low.Theyhaveaneconomicpotentialwhichisnotfully
realized;thisreferstounemployedlabour,naturalresources
andfertilityofthesoil.Scienceandtechnologyarenotfully
applied.Thelevelofliteracyislow
-itaveragesonly63per
centintheleastdevelopedcountries.Thequality
oflifeis
poorbecauseofthescarcityofessentialgoods,facilitiesand
money.There
isisolationcausedbydistance,poor
communicationandtransportlacilities.Theenvironment
is
unfavourablepredisposingtocommunicablediseasesand
malnutrition.Thevastmajorityofpeoplearenotabletopay
formedicalservices.There
isalongtraditionofireemedical
servicesprovidedbytheState.
Inthedevelopedcountries,mostpeople(8outof10)are
urbanresidents.Urbanliledifersfromthatinthevillagesby
beingmoreimpersonal.Womenareeconomicallyemployed.
Agricullureissecond
toindustry.Greatuseismadeofscientific
disciplines.Thestandardoflivingandqualityoflifearehigh.
TheGNPpercapitarangesfromUS$5000to40,600inmost
developedcountries.Theadultliteracyisalmostuniversal.
Inmid-2017,theWorldPopulationreached7.4billion.
ofwhich60percentliveinAsia.Thepopulation
n
developingcountries
isa"youngpopulation:
tne
proportionofpersonsunder15yearsofageinthe
year
2016wasabout41percentintheleastdevelopedcountries
and24inotherdevelopingcountries,ascomparedtoab0u
16percentinthedevelopedcountries.Theproportion
peopleover65yearsofageindevelopingcountries
Isabou
5percent,comparedto18percentinthedevelop
countries(69).Thesocialandeconomic
backlashes
ottni
agedistributionarebeingfeltinboththedevelopingd
developedcountries
-theformerhavingtobearthehedvy
burdenofprovidingforapopulationwhichismainlyyou
andthelatterhavingtodealwiththeproblems
ofageing
3.Contrastsinhealth(Healthgap)
even
2.Demographiccharacteristics
Demographictrendsfundamentallyinfluencecountry's
economic,socialandhealthconditions.Populationgrowth,
changesinfertilityratesandpopulationstructure,allhavea
profoundinfiuence,asdomigration(whichisincreasinglya
cross-borderissue)andgrowingurbanizationwhichmay
spureconomicgrowthbutals0putstrainonfoodandwater
Whileaccuratestatisticaldataaredifficulttoobtainl.
pertunctoryglanceatavailabledata(Table7)aresul
the
toillustratethewidehealihgapbetweenpopulato
developedanddevelopingcountries.
'a
Table7showsthatthepresentgapinhne
ntries
birthbetweendevelopedanddevelopingcoed
by
15-20years.DevelopedcountriesareC
dmortall
longerliteexpectancyandlowerinfantandchiia
rates,andtheopposite
istrueofdeveloping
cou
resources.
ntries.
Fertilityratesarefallinggloballyandasaconsequence,

7. 51
CHANGINGPATTERNOFDISEASE
disabilityandhandicapwhicharelaterstages
havelarge
tuberculosis,cardiacpatientsandothers.Thepurposeofocialandenvironnnmentalcomponents
interms
of
rehabilitationistomakeproductivepeopleoutofnon-
productivepeople.
dependenceandsocialcost(95).
Disabilityprevention
Anotherconceptis"disabilityprevention".Itrelatestoallthelevelsofprevention:(a)reducingtheoccurrence
ofimpairment,viz.immunizationagainstpolio(primaryprevention);(b)disabilitylimitationbyappropriatetreatment(secondaryprevention);and,(c)preventingthetransitionofdisability
intohandicap(tertiaryprevention)(115).
Themajorcausesofdisablingimpairmentsinthedeveloping
countriesarecommunicablediseases,malnutrition,lowquality
ofperinatalcareandaccidents.Theseareresponsibleforabout
70percentofcasesofdisabilityindeveloping
countries.
Primarypreventionisthemosteffectivewayofdealingwiththedisabilityproblemindevelopingcountries(115).
Itisnowrecognizedthatrehabilitationisadifficultand
demandingtaskthatseldomgivestotallysatisfactoryresults;
butneedsenthusiasticcooperationfromdifferentsegments
ofsocietyaswellasexpertise,equipmentandfundsnot
readilyavailableforthispurposeeveninaffluentsocieties.It
isfurtherrecognizedthatinterventionsatearlierstagesare
morefeasible,willyieldresults,andarelessdemandingof
Scarceresources.
CHANGINGPATTERNOFDISEASE
Althoughdiseaseshavenotchangedsignificantlythrough
humanhistory,theirpatternshave.Itissaidthatevery
decadeproducesitsownpatternofdisease.Thetruthofthis
willbeobviouswhenonecomparestheleadingcausesof
deathgloballyfortheyear2000and2020(118A).
5.Rehabilitation
Rehabilitationhasbeendefinedas"thecombinedandcoordinateduseofmedical,social,educationaland
vocationalmeasuresfortrainingandretrainingtheindividualtothehighestpossibleleveloffunctionalability"
(116).Itincludesallmeasuresaimedatreducingtheimpact
ofdisablingandhandicappingconditionsandatenabling
thedisabledandhandicappedtoachievesocialintegration
(115).Socialintegrationhasbeendefinedastheactive
participationofdisabledandhandicappedpeopleinthe
mainstreamofcommunitylife(117).
YEAR2000
Deaths
(000s)
%oftotal
deaths
Rank
Cause
Ischaemicheartdisease 7,029
5,170
3,325
2,972
1.
13.4
2.Stroke
9.9
Lowerrespiratoryinfections
Chronicobstructivepulmonary
disease
3.
6.4
4.
5.7
2,246
1,684
1,469
1,382
1,257
2.4
1,136s1E2.2
1,125i 2.2
5.Diarrhoealdiseases
4.3
6.Tuberculosis
3.2
ItinvolvesRehabilitationmedicineorPhysicalmedicineor
Physiatryhasemergedinrecentyearsasamedicalspeciality.
Itaimstoenhanceandrestorefunctionalabilityandqualityof
lifetothosewithphysicalimpairmentsordisabilities.A
physiatristspecializesinrestoringoptionalfunctiontopeople
withinjuriestothemuscles,bones,ligamentsornervous
system.Sixformalsub-specializationarerecognizedare:
neuromuscular
medicine,pain
rehabilitationmedicine,spinalcordinjurymedicine,sports
medicineandbrainmedicine.Paramedicalandnon-medical
persons
areinvolvedinthediscipline.Theyarephysical
medicineorphysiotherapy,occupationaltherapy,speech
therapy,audiology,psychology,education,socialwork,
VOcationalguidanceandplacementservices.Thefollowing
areasofconcerninrehabilitationhavebeenidentified:
(a)Medical
rehabilitation
-
restorationoffunction.
(6)Vocationalrehabilitation
-
restorationofthecapacity
toearnalivelihood.
7 HIV/AIDS
.8
8.
2.6
Pretermbirthcomplications
Trachea,bronchus,lungcancers
Roadinjury
Birthasphyxiaandbirthtrauma
Cirrhosisofthelever
9.
10.
11.
12.
988 1.9
13.Diabetesmellitus
944 .8medicine,paediatric
804
14 Alzheimerdiseaseandother
dementias
1.5
15.Self-harm
790 1.5
All
causes
52,307100.0
YEAR2020
Rank Deaaths
(000s)
%oftotal
deaths
Cause
8,138
4,987
2,624
Ischaemicheartdisease
16.59
10.16
2.Stroke
Chronicobstructivepulmonary
)Socialrehabilitationrestorationoffamilyandsocial
relationships.
d)Psychologicalrehabilitationrestorationofpersonal
dignityandconfidence.
3.
5.34
disease
Lowerrespiratoryinfections
(including8,64,000deathscaused
byCovid-19asofSep.2020)
Alzheimerdiseaseandother
dementias
2,551
5.2
1,718
Rehabilitation
isnolongerlookeduponasanextra-
rricularactivityofthephysician.Thecurrentviewisthat
responsibilityofthedoctordoesnotendwhenthe
peraturetouchesnormalandstitchesareremoved
3.5
Trachea,bronchus,lungcancers
Diabetesmellitus
6.
1,473
1,379
1,210
3.07
2.81
8
Roadinjury
Diarrhoealdiseases
2.47
patientmustberestoredandretrained"toliveandwork
9
wEninthelimitsofhisdisabilitybuttothehiltofhis
1,192
1,115
1,081
1,017
2.4310.Tuberculosis
2.27
actyAssuchmedicalrehabilitationshouldstartvery
Cirrhosisofthelever
Kidneydiseases
Pretermbirthcomplications
HIVIAIDS
Hypertensiveheartdisease
11.
12. 2.21
earlyintheprocess
ofmedicaltreatment.
2.07
amplesofrehabilitationare:establishingschoolstor
Surnoprovisionofaidsforthecrippled,reconstructive
13
14
874
1.7
1.78
872
Surgery
inleprosy,musclere-education
and for
amore
nneurological
disorders,hangeofprofessionforamore
bleone
andmodificatoflifeingeneralinthecaseof
15.
774 1.58
Allcauses
60,791
100.0

8. 56
CONCEPTOFHEALTIHANDDISEASE
thecommunity,withspecialattentiontovulnerablegroups.
Thefunctionsofthehealthcentrearediscussedelsewhere.
Thefunctionsofadoctor(physiclan)maybesummarizedas
follows:
thewishesofthepeople,asrevealedby
Com.
diagnosis.Improvermentotwatersupplies,immunni
healtheducation,Control,Ospeciticdiseases,h
legislationareexamplesofcommunityhealth
ac
interventions.Actionmaybetakenatthreelevele
leveloftheindividual,atthelevelofthefamilyand
levelofthecommunity(137).
(a)Thecareoftheindividual:Aphysicianmustbeableto
assessthestateofhealthoftheindividual.Thiswould
includeaclinicaldiagnosis,asimplelaboratorydiagnosisas
wellasanassessmentoftheindividual'sstateofnutrition,
levelofdevelopment,socialandemotionalstateandthe
healthneeds.Hemustthenbeabletotakeanyfurther
measuresnecessaryfortreatment,preventionandreferralto
higherlevelsofhealthcare.Hemustbeparticularlyexpert
incommonconditions,infirst-aidandinthemanagementof
acuteemergencies.Becauseofthelargenumbersinvolved,
hemustknowhowtodelegateworktohisauxiliaries.
at
the
Aprogrammeofcommunityactionmusthavo
followingcharacteristics:(a)itmusteffectivelyutilizeall
availableresources,(b)itmustcoordinatetheeffortsof
otheragenciesinthecommunity,nowtermed
"intersectoralcoordination,and(c)itmustencouraget
fullparticipationofthecommunityin
the
programme.Thea
aretheprinciplesonwhichprimaryhealthcare,asdefine
intheAlma-AtaDeclaration,isbased.Thisapproachisa
significantdeparturefromtheearlierbasicservin
approach.
(b)Thecareofcommunity:Thecareofthecommunity
centresroundtheeightessentialelementsofprimaryhealth
careasstatedintheAlma-AtaDeclaration(seepage37)
Thephysicianistheleaderofthe"healthteam".He
providesprimaryhealthcarethroughthehealthteamatthe
grass-rootlevel.Heshouldbefamiliarwithcommunity
diagnosis,prioritizationofhealthproblemsandcommunity
rvic%
DISEASECLASSIFICATION
Thereisawidevariationamong
countriesinthecriteria
andstandardsadoptedfordiagnosisofdiseasesandthet
notification,makingitdifficulttocomparenationalstatistis
Asystemofclassificationwasneededwherebydiseasescoul
begroupedaccordingtocertaincommoncharacteristics,
tha:
wouldfacilitatethestatisticalstudyofdiseasephenomera
Overtheyears,manyapproachesweretriedtoclassi;
diseases.JohnGrauntinthe17thcenturyinhisstudyofBil
ofMortality,arrangeddiseasesinanalphabeticalorde
Later,amorescientificapproachwasadoptedinclassiting
diseasesaccordingtocertaincharacteristicsofthediseasec
injuriessuchas(a)thepartofthebodyaffected
(6)te
aetiologicagent(c)thekindofmorbidchangeproduced
ty
thedisease,and(d)thekindofdisturbanceoffuncicn
producedbythediseaseorinjury.Thustherearemany
ax
ofclassification,andtheparticularaxisselectedwilldepent
ontheinterestoftheinvestigator(138).
treatment.
(c)Thephysicianasateacher:Theterm"doctorby
derivationmeanstoteach.Thereforethephysicianhasa
majorresponsibilityasateacherandeducator.Inhis
practice,inhisprofessionalassociationsandinhis
communityactivities,thephysicianhaswideeducational
opportunities.Butunfortunately,thephysician'sroleasa
teacherisaneglectedone.Manyphysiciansarereluctantto
capitalizeontheirroleaseducators.Asateacher,the
physiciancanplayaneffectiveroleincommunityhealth
educationsothatindividuals,familiesandcommunities
assumegreaterresponsibilityfortheironhealthand
welfare,includingself-care.Hecanalsogenerateand
mobilizecommunityparticipationinhealthprogrammes
througheffectivepropagationofrelevantinformation.
Internationalclassificationofdiseases
Communitydiagnosis
Thediagnosisofdiseaseinanindividualpatientisa
fundamentalideainmedicine.Itisbasedonsignsand
symptomsandthemakingofinferencesfromthem.When
thisisappliedtoacommunity,itisknownascommunity
diagnosis.Ihecommunitydiagnosismaybedeinedasthe
patternofdiseaseinacommunitydescribedintermsofthe
importantfactorswhichinfluencethispattern(137).
AlltheabovecriteriaformedthebasisoftheInternation
classificationofdiseases(ICD)producedbyWHO
an
acceptedintheyear1940fornationalandinternational
us
Sinceitsinception,
ICDhasbeenrevisedaboutonceever
10years;the10threvision,cameintoeffectonJanuar
1993.Earlier,thescopeofICDwasexpandedinthe
SI
revisionin1948tocovermorbidityfromillnessandinjui
TheICDalsoprovidesabasisthatcanbeadaptedfor
use
otherfields.Thecommunitydiagnosisisbasedoncollectionand
interpretationoftherelevantdatasuchas(a)theageand
sexdistributionofapopulation;thedistributionof
populationbysocialgroups;(b}vitalstatisticalratessuchas
thebirthrate,andthedeathrate;(c)theincidenceand
prevalenceoftheimportantdiseasesofthearea.In
addition,adoctormustbeabletofindinformationona
widevarietyofsocialandeconomicfactorsthatmayassist
himinmaingacommunitydiagnosis.Thefocusisonthe
identificationofthebasichealthneedsandhealthproblems
ofthecommunity.Theneedsasfeltbythecommunity
(Someofwhichmayhavenoconnectionatallwithhealth)
shouldbenextinvestigatedandlistedaccordingtopriority
forcommunitytreatment
ICDisthefoundationfortheidentification
othed
trendsandstatisticsgloballyand
istheinternatio
standardforreportingdiseasesandhealthconditions.
diagnosticclassificationstandardforallclinicaland
resea
purposes.ICDdefinestheuniverseofdiseases,disoru
injuriesandotherrelatedhealthconditions,listed
comprehensive,hierarchicalfashionthatallowsto
storage,retrievalandanalysisofhealthinformatiou
evidence-baseddecision-making;sharingandcompand
healthinformationbetweenhospitals,regions,sertrs
Countries;anddatacomparisoninthesamelocatio
differenttimeperiod.
t
is
a
Communitytreatment ICD-11(139)
ntury
to
TheICD-11hasbeenupdated
forthe21st
c ove
wilthCommunitytreatmentorcommunityhealthactionisthe
sumofstepsdecidedupontomeetthehealthneedsofthe
communitytakingintoaccounttheresourcesavailableand
w
retlectthesignificantprogressinscienceandme
thepast30yearsandhasbeendesignedforthe
ue

9. 57DISEASE
CLASSIFICATION
unity
tion,
ealth
15.Diseasesofthemusculoskeletalsystemandconnective
tissue.
diaitalhealthapplicationsandapplicationsystems.The
diaitalplatformfor
ll
can
beaccessedonlineor
downloadedremotelyfreeofchargeandinmultiple
languagesviatheonlinebrowser.ltcomprisesover55,000
entities.
Besidesdiseases,ICDincludesdisorders,injuries,
16.Diseasesofthegenitourinarysystem.
17.Conditionsrelatedtosexualhealth.
or
18.Pregnancy,childbirthandthepuerperium.
19.Certainconditionsoriginatingintheperinataland
neonatalperiod.
20.Developmentalanomalies.
21.Symptoms,signsorclinicalfindings,notelsewhere
classified.
the
the
andsymptoms,
substances,externalcauses,
medicaments,anatomy,devices,histopathology,severity
andmuchmoreandl20,000clinicalterms(andcancode
millionsofterms),withthousandsofnewcategoriesand
undatedclassificationschemes,andisintendedtosupersede
the10thRevision,whichwasmorethan28yearsoldand
clinicallyoutdated.
Newto1CD-11isachapteronsexualhealth,which
bringstogetherseveralconditionsthatwerepreviously
classifieddifferently.Genderincongruenceisincludedinthis
newchapter,reflectinganunderstandingthatitisnota
mentalhealthcondition.Re-classificationshouldhelpto
reducethestigmaattachedtogender-definedstates.
Anothernewchapterfocusesontraditionalmedicine,
commonlyusedacrossmanycountrie.Inalandmark
decision,strokeisnowlistedasaneurologicaldisorderand
notasadisorderofthecirculatorysystem.Thisimportant
changewaslongoverdueanditbringsstrokeoutofthe
shadowofheartdisease.
signs
the
the
all
as
22.Injury,poisoningorcertainotherconsequencesof
externalcauses.
the
hese
23.Externalcausesofmorbidityandmortality.
24.Factorsinfluencinghealthstatusorcontactwithhealth
ined
isa
ices
services.
25.Codesforspecialpurposes.
26.Supplementary
Conditions
-
ModuleI.
V.Supplementarysectionforfunctioningassessment.
TraditionalMedicinechapter,
eria
heir
tics.
X.Extensioncodes.
Linkageswithotherclassificationsand
terminologies(139)
TheICD-11incorporatesonlinkswiththefollowing
classificationsandterminologiesthroughtheICD-11
foundation
buld
that
ena.
Ssify
Bills
der.
ThenewclassificationofHIVrecognizesadvancesinHIV
therapy,whichshouldbeseenasachroniccondition.
Allergyiscodedunderdiseasesoftheimmunesystem.
Attentiondeficithyperactivitydisorder'supdateddescription
statesthatthesymptomsnolongerhavetooccurwithin
fixedagerangetoleadtodiagnosis.Theupdatesalso
enablebetterreportingofantimicrobialresistance,with
codesthataremoreinlinewiththeGlobalAntimicrobial
ResistanceSurveillanceSystem.
a.InternationalClassificationofDiseaseforOncology
ICD-O
Jing
2or
b.InternationalClassificationofExternalCausesofInjury
-
ICECI
the
!
by
tion
Ixes
end
InternationalClassificationofFunctioning,Disabilityand
Health
-1CF
InthisiterationoftheICD,specialattentionhasbeen
dedicatedtomentalhealth.Simplerdiagnosticdescriptions
willmakementalhealthdiagnosismoreaccessibleto
health-careprofessionalsglobally.Forinstance,theICD-11
listofpost-traumaticstressdisordercriteriahavebeen
reducedtofacilitateeasierdiagnosisandimproveaccessto
treatment.Addictiveconditions,suchasgamingand
hoardingdisorders,havebeenadded.Compulsivesexual
behaviourwasincludedasanimpulsecontroldisorder.
dInternationalClassificationofPrimaryCareICPC
andasOrphaNetterminologiessuche.Other
SNOMED-CT
nal
and
se
ery
TheInternationalClassificationofFunctioning,
DisabilityandHealth(1CF)(140)
TheICFisaframeworkfororganizinganddocumenting
informationonfunctioninganddisability(WHO2001).It
conceptualizesfunctioningasa"dynamic interaction
betweenaperson'shealthcondition,environmentalfactors
andpersonalfactors".
1,
TheInternationalClassificationofDiseases11thRevision
hasbeenadoptedbytheWorldHealthAssemblyin2019
anditwillcomeintoeffectfrom1stJanuary2022.
The1CD-11containsfollowingchapters
Certaininfectiousandparasiticdiseases.
2.Neoplasms.
3.Diseasesofbloodandbloodformingorgans.
4Disordersoftheimmunesystem.
Endocrine,nutritionalandmetabolicdiseases.
xth
ry.
in
ICFprovidesastandardlanguageandconceptualbasis
forthedefinitionandmeasurementofdisability,andit
providesclassificationandcodes.Itintegratesthemajor
modelsofdisability
the
medicalmodelandthesocial
model-asabio-psycho-socialsynthesis.It
recognizesthe
roleofenvironmentalfactorsinthecreationofdisability,as
wellasthehealthconditions.
Ith
al
a
ch
rS,
OMental,behaviouralorneurodevelopmentaldisorders
7Sleep-wakedisorders.
8Diseaseofthevisualsystem.
9Diseasesofthenervoussystem..
Diseasesoftheearandmastoidprocess.
11.Diseasesofthecirculatorysystem.
12.Diseasesoftherespiratorysystem.
13Diseasesofthedigestivesystem.
14.Diseasesoftheskin.
Functioninganddisabilityareunderstoodasumbrella
termsdenotingthepositiveandnegativeaspectsof
functioningfromabiological,individualandsocial
perspective.1CKtheretoreprovidesdefinitionsand
categoriesinneutrallanguage,whereverpossible.ICFis
aetiology
-
neutral,i.e.,disabilityisnotdifferentiatedby
aetiology.TheICFcoverstheentirelifespan.ICForganizes
informationintwoparts.Part1
dealswithfunctioningand
disabilitywhilepart2coverscontextualfactors.Eachpart
hastwocomponents:
19
d

10. 111IMMUNIZING
AGENTS
sufficientlyhigh,theoccurrenceof
dmicisregardedashighlyunlikely.Ifthathighlevel
andsteppedup,byanon-going
thepointwherethe
reducedtoasmallproportionofthe
vaccineisan
immuno-biologicalsubstance
designedto
producespecificprotectionagainstagivendisease.
t
Stimulatestheproductionofprotectiveantibodyandother
mmunemechanisms.Vaccinesmaybepreparedfromlive
moditiedorganisms,inactivatedorkilledorganisms,
extractedcellularfractions,toxoidsorcombinationofthese.
theherd
immunityis
of
immunityismaintained,
nizationprogramme,to
an
epidemici
ulation,itmayleac(butnotnecessarily)toeliminatioon
diseasesas theriaandpoliomyelitis.Inthecaseof
Sceptiblepersonsare
of
thePodiseaseinduecourse.Thishasbeenachievedinsuch
a.Livevaccines
Livevaccines(e.g.,BCG,measles,oralpolio)are
preparedfromliveorwild(generallyattenuated)organisms.
hese
organismshavebeenpassedrepeatedlyinthe
laboratoryintissuecultureorchickembryosandhavelost
theircapacitytoinducefull-blowndiseasebutretaintheir
immunogenicity.Ingeneral,livevaccinesaremorepotent
immunizingagentsthankilledvaccines,thereasonsbeing:
(1)liveorganismsmultiplyinthehostandtheresulting
antigenicdoseislargerthanwhatisinjected,(ii)live
vaccineshaveallthemajorandminorantigenic
components,(ii)livevaccinesengagecertaintissuesofthe
body,asforexample,intestinalmucosabytheoralpolio
vaccine,and(iv)theremaybeothermechanismssuchas
thepersistenceoflatentvirus.
itmaybementionedthatitwasnotherdallpox,
however,
nity(althoughimportantasitwas)thatplayeda
cTucial
roleinitseradication,buteliminationofthesource
finfection,bysurveillanceandContainmentmeasures.
withtheabolitionoivaccinationagainstsmallpox,theherd
immunityinthecaseofsmallpoxwillnaturailytendto
declinewiththepassageoftime.Inthecaseoftetanus,
however,herdimmunitydoesnotprotecttheindividual.
Studieshaveshownthatitisneitherpossiblenor
necessarytoachieve100percentherdimmunityina
populationtohaltanepidemicorcontroldisease,asfor
example,eradicationofsmallpoxandpoliomyelitis.Just
howmuchlessthan100percentisrequiredabovewhich
thediseasemaynolongerexist,isacrucialquestion.
Theproportionofimmuneindividualsinapopulation,
abovewhichadiseasemaynolongerpersist,isherd
immunitythreshold.It'svaluevarieswiththevirulenceofthe
disease,theefficacyofthevaccineandthecontact
parameterforthepopulation.
Herdimmunitymaybedeterminedbyserologicalsurveys
(serologicalepidemiology).
Livevaccinesshouldnotbeadministeredtopersonswith
immunedeficiencydiseasesortopersonswhoseimmune
responsemaybesuppressedbecauseofleukaemia,
ymphoma ormalignancyorbecauseoftheraPywith
corticosteroids,alkylatingagents,antimetabolicagents,or
radiation(117,118).Pregnancyisanothercontraindication
unlesstheriskofinfectionexceedstheriskofharmtothe
foetusofsomelivevaccines.
Whentwolivevaccinesarerequiredtheyshouldbegiven
eithersimultaneouslyatdifferentsitesorwithanintervalof
atleast3weeks.nthecaseoflivevaccines,protectionis
generallyachievedwithasingledoseofvaccine.An
additionaldoseisgiventoensureseroconversion,e.g.,95to
98percentofrecipientwillrespondtosingledoseof
measlesvaccine.Theseconddoseisgiventoensurethat
100percentofpersonsareimmune.Theotherexceptionis
poliovaccinewhichneedsthreeormoredosestobegiven
atspacedintervalstoproduceeffectiveimmunity.Live
vaccinesusuallyproduceadurableimmunity,butnot
alwaysaslongasthatofthenaturalinfection.
Livevaccinesmustbe
properlystoredtoretain
effectiveness.Seriousfailuresofmeaslesandpolio
IMMUNIZINGAGENTS
Theimmunizingagentsmaybeclassifiedasvaccine5,
immunoglobulinsandantisera.
Vaccines
Overthelastcentury,vaccinationhasbeenthemost
effectivemedicalstrategytocontrolinfectiousdiseases.
Smallpoxhasbeeneradicatedworld-wideandpoliomyelitis
hasbeenalmosteradicated.
diseasestraditionallyaffectingchildrenworld-widearenow
preventablebyvaccines.Vaccinationisestimatedtosaveat
least2-3millionliveseveryyear.Thevaccinescurrently
usedareasshowninTable29.
Mostviralandbacterial
TABLE29
Vaccinescurrentlyinuse
PolysaccharideGlycoconjugateRecombinant
Killedwholeorganismloxoid/Protein
Diphtheria
Liveattenuated
Hib HBV
Lymedisease
CholeratoxinB
Pneumococcus
Tuberculosis(BCG)
Yellow
fever
PolioOPV
Measles
Mumps
Rubella
yphoid
Varicella
Rotavirus
Cholera
oldadaptedinfuenzaHAV
Rotavirusreassortants
Zoster
Typhoid
Cholera
Plague
PneumococcusMeningococcus
Hib
Tetanus
AcellularPertussis MenACWY
HPV
COVID-19
Typhoid(Vi
Pertussis
Influenza
Tuphus
Anthrax
Iníluenzasubunit
Polio(IPV)
Rabies
JE
TBE
COVID-19
BacillecalmeteGuerin,HAVhepatitisAvirus;HBVhepatitis
5rus;HibHaemophilusinfluenzaetypeb:
vated
Poliovaccine,JEJapaneseencephalitis;MenmeningocoCcus,oral
pol10vaccine;TBEtick-borneencephaliticBEG
Source(116)

11. circulating
antibody.
They
areoften
morestabletha
attenuated
vaccines.
anlive
Some
featuresof
attenuated
vaccines
versusina
(killed)
vaccinesarelistedin
Table30and
someof
tvated
important
developmentsinthe
fieldofvaccinesareliery
Table31.
112
PRINCIPLESOF
EPIDEMIOLOGYAND
EPIDEMIOLOGIC
METHODS
immunizationhave
resulted
from
inadequate
refrigeration
priortouse tedin
Inactivatedvaccinesare
producedby
growingvirusor
bacteriainculturemediaandthen
inactivatingthemwith
heator
chemicals
(usually
formalin),wheninjectedintothe
bodythey
stimulateactive
immunity.Theyareusuallysafe
but
generally,less
efficaciousthanlivevaccines.Forexample,
choleravaccine
offersonly50percent
protection.
The
efticacyof3dosesofpertussisvaccine
isabout80percentin
the
firstthreeyears,andalmost
"'nil12yearsafter
immunization.
Killedvaccines
usuallyrequireaprimaryseries
of2or3dosesofvaccinetoproduceanadequateantibody
response,andinmostcases"booster"
injectionsarerequired.
Thedurationofimmunity
followingtheuseofinactivated
vaccinesvariesfrommonthstomanyyears.
Inactivatedpolio
vaccinehasbeenquiteaneffectivevaccine,the
widespread
useofwhichincertaincountrieshasledtotheeliminationof
thedisease.Killedvaccinesareusually
administeredby
subcutaneousorintramuscularroute.
b.Inactivatedor
killedvaccines
TABLE30
Comparisonof
characteristicsotkilledand
livevaccino
Live
nes
Killed
vaccinevaccine
Characteristic
Single
No
Mutiple
Numberofdoses
Needforadjuvant
Durationof
immunity
Yes
ShorterLonger
Lower Greater
Effectivenessof
protection
(morecloselymimicsnatural
infection)
IgG lgAandlgG
Immunoglobulinsproduced
Mucosalimmunity
produced
Cell-mediatedimmunityproduced
Poor Yes
Poor Yes
PossibleNo
Residualvirulentvirusinvaccine
PossibleNo
Reversiontovirulence
No Possible
Becausethevaccine
isinactivated,theinfectiveagent
cannotgrowinthevaccinatedindividualandtherefore,can
notcausethedisease,eveninanimmunodeficientperson.
Theonlyabsolutecontraindicationtotheiradministration
isaseverelocalorgeneralreactiontoapreviousdose.
Unlikeliveantigens,inactivitedantigensarenotaffectedby
Excretionofvaccinevirusand
transmissiontonon-immune
contacts
No Possible
Interferencebyothervirusesinhost
Stabilityatroomtemperature
High Low
Source:(119)
TABLE31
Milestonesinvaccination
Japaneseencephalitisvaccine.
Varicellavaccinelicensed.
1993
1798
1885
1897
Smallpoxvaccine
Rabiesvaccine
1995
HepatitisAvaccinelicensed.
Acellularpertussisvaccine(DTaP)licensedforuse
inyounginfants.
Pneumococcalconjugatevaccine(Prevnar)
recommendedforallyoungchildren.
Firstliveattenuatedinfluenzavaccinelicensed(FluMist)
forusein5to49yearoldpersons.
FirstAdultImmunizationScheduleintroduced.
1995Plaguevaccine
Choleravaccine1917 1996
Typhoidvaccine(parenteral)
Diphtheriatoxoid
Pertussisvaccine
1917
1923 2000
1926
1927Tuberculosis(BCG)
TetanustOxoid
2003
1927
1935 Yellowfevervaccine 2003
DTP
Thefirstinfluenzavaccines
1940s
2004Inactivatedinfluenzavaccinerecommendedtorall
1945
1955
1955
1961
1963
1963
1967
Inactivatedpoliovaccine(1PV).
Tetanusanddiphtheriatoxoidsadsorbed(adultuse,Td)
Monovalentoralpoliovaccine
Trivalentoralpoliovaccine(OPV).
Thefirstmeaslesvaccine
children6to23monthsofage.
Pediarix,avaccinethatcombinestheDTaPIPV,and
HepBvaccines,intooneshot,isapproved.
BoostrixandAdacel,Tdapvaccines,areapproved
forteens.
2004
2005
2005Menatra,anewmenigococcalvaccineisapprovedtor
peoplebetweentheageof11to55years.
RotaTeqisanewrotavirusvaccinefromMerck.
ProQuadisanewvaccinethatcombines
theMMRandVarivaxvaccinesformeasles,mumps,
rubella,andchickenpoxintoasingleshot.
Gardasil,
thefirstHPV
vaccineisapproved.
AboosterdoseofVarivax,thechickenpoxvaccine,isrecommended
forallchildren.
1969
1970
Mumpsvaccine
Rubellavaccine
2006
Anthraxvaccine
1971Measles,Mumps,Rubella(MMR)
vaccineIicensed.
Fluzone,thecurrentfluvaccine.
Smallpoxdeclarederadicatedfromtheworld.
Meningococcal
polysaccharide
vaccine,
groupsA,C,Y,W135combined(Menomune)
HepatitisB
vaccine
Pneumococcal
vaccine,23valent
WorldwidePolioEradication
Initiative
launched;supportedbyRotaryInternational,
CDCandothers.TheVaccineAdverse
ReportingSystem(VAERS),
anational
programme
monitoring
thesafetyofvaccinesestablished.Haemophilus
influenzae
typeB(Hib)polysaccharideconjugatevaccinelicensedforinfants.
Typhoid
vaccine(oral)
HepatitisBvaccinerecommended
forallinfants.Acellular
pertussis
vaccine(DITaP)
licensed
forusein
olderchildren
agedl5monthstosixyearsold.
1978
1980
1981 2006
2007
1982
1983
1988
2007
Therecommended
ageforFlumist,thenasalsprayfluvaccine,wasloweredtotwoyears.
Rotarix,atwodoserotavirus
vaccineisapproved.Influenza-A
(HN,)vaccineapproved.FDA
approvedthefirst
vaccine(Menactra)toprevenmeningococcal
diseaseininfantsandtoddlers.FDA
approved
Boostrix
Tdap(GlaxoSmithKlin)topreventtetanus,
diphtheria
andpertussisinolderp
HPV
vaccineforadolescent
boys.Approved
quadrivalent
formulation
offluarix.Inactivated
andintranasal
influenzavaccine-qua
COVID-19
2008
1990
2009
2011
1990
1990
1991
1991
2012
2013
Source:(120)
2020
quadrivalent

12. MMUNIZATICONSCHEDULES 135
TABLE43
NationalIminunizationSchedule(NIS)foriniants.
childrenandpregmant
wo1-n(vaccine-wise).india212}
Whentoglve
/Vaccine Dose Route
Site
For
Pregnant
Women
Tetanus
Toxoid(TT)
Tetanus
&adult
Diphtheria
(Td)-1
TT/Td-2
Earlyinpregnancy
0.5ml Intra-muscular
UpperArm
4weeksafterTT-1
0.5ml Intra-muscular
UpperArm
Ifreceived2TTdosesinapregnancy
withinthelast3years*"
TTTd-Booster
UpperArm
0.5ml Intra-muscular
For
Infants
Bacillus
Calmette
Guerin
(BCG)
Atbirthorasearlyaspossible
tilloneyearofage
Intra-dermal
LeftUpperArm
0.1ml(0.05ml
until
1monthage)
HepatitisB-
Birthdose
Atbirthorasearlyaspossible
within24hours
Antero-lateral
sideofmid-thigh
0.5ml Intra-muscular
OralPolioVaccine
(OPV)-0
Atbirthorasearlyaspossible
withinthefirst15days
2drops Oral
Oral
At6weeks,10weeks&14weeks
(OPVcanbegiventill5yearsofage)
Oral
OPV1,2&3
2drops Oral
At6weeks,10weeks
&14weeks
(canbegiventilloneyearofage)
Antero-lateral
sideofmid-thighPentavalent1,2&3 0.5mi Intra-muscular
Twoprimarydosesat6and14weeks
followedbyboosterdoseat9-12months
Antero-lateral
sideofmid-thigh
0.5ml
Intra-muscular
Pneumococcal
Conjugate
Vaccine(PCV)
Orat
At6weeks,10weeks&14weeks
(canbegiventilloneyearofage)
Rotavirus(RVV)
3drops Oral
RightUpper
Twofractionaldoseat6and14weeks
ofage
Intradermal,two
fractionaldose
0.1mlID
InactivatedPolio
Vaccine(IPV)
Arm
RightUpper
Arm
0.5ml Sub-cutaneous
MeaslesRubella
(MR)1stdose
9completedmonths-12months.
(Measlescanbegiventill5yearsofage)
9completedmonths-12months. 0.5ml Sub-cutaneous
LeftUpperArm
Japanese
Encephelitis
JE)-1**
1ml Oral
Oral
VitaminA(1stdose) At9completedmonthswith
Measles-Rubella
(1lakh1U)
ForChildren Antero-lateral
sideofmid-thigh
0.5ml
Intra-muscular
16-24monthsDiphtheria,
Pertussis&
Tetanus(DPT
booster-1
0.5mi Sub-cutaneous
RightUpperArm
MR2nddose 16-24months
2drops Oral
Oral
OPVBooster 16-24months
1F2
0.5ml Sub-cutaneous
LeftUpperArm
16-24months
Oral Oral
taminA
2ndto9thdose)
16-18months.Thenonedoseevery
6
monthsuptotheageof5
ycars
2ml
(2lakhIU)
DPTBooster:2
0.5ml.
Intra-muscularUpperArm
5-6yearS
0.5ml
Intra-muscularUpperArm
10years
&16
years
edoseifpreviouslyvaccinatedwithin3years
ne
is
introducedinselect
endemic
districtsafterthe
campaign.
to
9thdosesof
VitaminAcanbe
administeredtochildren1-5
yearsOldduringbl-annualrounds,incollaborationwithICDs.
p selected
states/districts:Bihar,
HimachalPradesh,
Madhya
Pradestn,FlaryanaState
initiative),UttarPradesh(19
districts)
&
aasthan18
districis)
Source
(143A)

13. 137IMMUNIZATIONSCHEDULES
successofEPIisnowbeingseentohave
patterr
tantlong-termeftectsonthetraditionalepidemiological
imnsofmajorintectiousdiseases,oftenraisingtheaverage
of
incidence,the
acentanimportantadditionaltargetgroupfor
nization.
Inthepre-immunizationera,largeproportion
adultshaddiseaseinducedimmunitytocommon
ctions,nowmajorityofindividualshavevaccineinduced
Servicesoraspartofdiseaseeliminationoreradication
measure.
Adolescencepresentscertainchallengesforimmunization
in
relationtolifestyleandothersocialissues,whilealso
offeringspecialopportunities,suchasavaccinedeliveryin
thesettingofeducationalinstitutions.Thevaccinesot
interestareMRandMMRaspartofmeaslesoutbreak
preventionoreliminationcampaign,Tdasboosterdosefor
neonataltetanuselimination,hepatitisB,influenza,varicella
andHPVvaccinesetc.
adolescentagegroupof10-19years
immunity,whichmayormaynothavethesamelong-term
ctability.Questionstheretoreariseastopolicyandstrategy
implicationsforpost-infancyimmunizationprogrammes.
The
WHOScientificAdvisoryGroupofExpertstoEPI
hasindicatedtheneedtoexpandimmunizationactivities
heyondinfancy,eitheraspartofroutineimmunization
Immunizationofhealthcareworkers:Theinformation
Table45isprovidedbyWHOtoassistcountriestodevelop
policiesforthevaccinationofhealthcareworkers,asperthe
nationalvaccinationscheduleinuseintheircountries.
TABLE45
Immunizationofhealthcareworkers
VaccinationofHealthCareWorkersrecommended
BCGvaccinationisrecommendedforunvaccinatedTST-orIGRA-negativepersonsatriskofoccupationalexposurTe
inlowandhighTBincidenceareas(e.g.health-careworkers,laboratoryworkers,medicalstudents,prisonworkers,
otherindividualswithoccupationalexposure)
Antigen
BCG
HepatitisB
mmunizationissuggestedforgroupsatriskofacquiringinfectionwhohavenotbeenvaccinatedpreviously(tor
exampleHCWswhomaybeexposedtobloodandbloodproductsatwork).
AllHCWsshouldhavecompletedafullcourseofprimaryvaccinationagainstpolio.
Polio
iphtheria HCWswhomay
haveoccupationalexposuretoC.diphtheriae.Allhealth-careworkersshouldbeuptodatewith
immunizationasrecommendedintheirnationalimmunizationschedules.
AllHCWsshouldbeimmunetomeaslesandproof/documentationofimmunityorimmunizationshouldberequiredas
aconditionofenrollmentintotrainingandemployment.
Measles
Rubella frubellavaccinehasbeenintroducedintothenationalprogramme,allHCWsshouldbeimmunetorubellaandproof
documentationofimmunityorimmunizationshouldberequiredasaconditionofenrollmentinto
trainingand
employment.
Oneboosterdose3-5yearsaftertheprimarydosemaybegiventopersoi
exposure,includingHCWs.
Meningococcal
consideredtobeatcor edriskof
Influenza
Varicella
HCWsareanimportantgroupforinfluenzavaccination.Annualimmunizationwithasingledoseisrecommended.
Countriesshouldconsidervaccinationofpotentiallysusceptiblehealth-careworkers(i.e.unvaccinatedandwithno
historyofvaricella)with2dosesofvaricellavaccine
Pertussis
Antigen
Tetanus
Haemophilus
|influenzaetypeb
Pneumococcal
HWCsshouldbeprioritizedasagrouptoreceivepertussisvaccine
NocurrentrecommendationforvaccinationofHealthCareWorkers
ThereiscurrentlynorecommendationregardingHCWs.
Themainburdenofdiseaseliesininfantsunder5yearsofage.Workinahealthcaresettingisnotindicatedasa
factorforincreasedrisk.ThereiscurrentlynorecommendationregardingHCWs.
Themainburdenofdiseaseliesininfantsunder5yearsofage.Immunocompetentadultsarenotatanincreasedriskfor
seriouspneumococcaldisease.HCWsarenotindicatedasagroupatincreasedriskofpneumococcaldisease.
Childrenarethetargetgroupforrotavirusvaccinationastheyhavethegreatestburdenofdisease.Adultsincluding
HCWsarenotatincreasedriskofseveredisease.
Rotavirus
HPV
dapanese
Encephalitis
Yellow
Fever
HCWsarenotatincreasedriskofHPV.Theprimarytargetgroupforvaccinationisgirlsaged9-14.
Health-careworkersaregenerallynotatspecialriskofcontractingJE.Workersathigh-riskinendemicareas,suchas
thoseinvolvedinvectorcontrol,shouldbevaccinated.
Individualsinendemiccountriesandtravellerstothesecountriesshouldreceiveasingledoseofyellowfevervaccine.
Workinahealthcaresettingisnotindicatedasafactorforincreasedrisk.Thereiscurrentlynorecommendation
regardingHCWs.
Health-careworkersaregenerallynotatspecialriskofcontractingJE.Workersathigh-riskinendemicareas,suchas
thoseinvolvedinvectorcontrol,shouldbevaccinated.
Typhoidvaccinesshouldbeemployedaspartofcomprehensivecontrolstrategiesinareaswherethediseaseisendemic.
Workinahealthcaresettingisnotindicatedasatactortorincreasedrisk.Thereiscurrentlynorecommendation
regardingHCWs.
Choleravaccinesmaybeemployedaspartofcomprehensivecontrolstrategiesinareaswherethediseaseisendemicas
wellasto
preventandrespondtocholeraoutbreaks.
1
hereiscurrentlynorecommendationregardingHCWs.
HepatitisAis
transmittedthroughcontaminatedfoodandwaterordirectcontactwithaninfectiousperson.HCWsare
notindicatedasagroupatincreasedriskofhepatitisAinfection.
PrEP
may
beconsideredformedicalprofessionalswhoregularlyprovidecaretopersonswithrabies.
Routinemumps
vaccinationisrecommendedincountrieswithawell-established,effectivechildhoodvaccinati
programmeandthecapacitytomaintainhighlevelvaccinationcoveragewithmeaslesandrubellavaccination.
HCWs
arenotindicatedasagroupatincreasedrisk.
ick-borne
Encepalitis
yphoid
Cholera
Hepatitis
A
Rabies
Mumps
Dengue
(CyDTD
HCWs
arenotatincreasedriskofdengue
Source:
(144A)

14. PRINCIPLESOFEPIDEMIOLOGY ANDEPIDEMIOLOGICMETHODS
autoclavingfor20minutesat20lbspressure.Alternatively,
thepatientmaybeaskedtospitinasputumcuphalffilled
with5percentcresol.Whenthecupisfull,itisallowedto
standforanhourandthecontentsmay
beemptiedand
disposedoff.
Presently,WHOadvisesagainsttheuse
humanuse,asitcancauseSKinirritationandrespirator
tractallergy;anditdoesnotgiveprotectionfromthe
infectiveagentintherespiratorytract.
tunnel
for
atory
Guidelinesondisinfectionofcommonpublic
placesincludingoffices(156)
Itprovidesinterimguidanceabouttheenvironmental
cleaning/decontamiationofcommonpublicplacesincluding
officesinareasreportingCOVID-19.
3.Room
Osuallythoroughcleaning,airingandexposuretodirect
sunlight,whenpossible,forseveralhourswillbesufticient.If
necessary,floorsandhardsurfacesintheroomshouldbe
prohibitedfor48hours(152).Forchemicaldisinfection,
floorsandhardsurfacesshouldbesprayedormoppedwith
oneofthefollowingdisinfectants:chlorinepreparations
Suchaschlorinatedlimeinconcentrationsthatleave25ppm
ormoreoffreechlorine;formaldehydesolutionata
concentrationof
1percentormore;phenolicdisinfectants
suchas27,percentcresol.Thesolutionshouldremainin
contactwiththesurfaceforatleast4hoursbeforefinal
washing(152).
1.Indoorareasincludingofficespaces
Otficespaces,includingconferenceroomsshouldbe
cleanedeveryeveningafterofficehoursorearlyinthe
morningbeforetheroomsareoccupied.Ifcontactsurfaceis
visiblydirty,itshouldbecleanedwithsoapandwaterprior
todisinfection.Priortocleaning,theworkershouldwear
disposablerubberb0ots,gloves(heavyduty),andatriple
layermask.
'
Onrareoccasions,whenfumigationisrequired,thegas
mostcommonlyusedisformaldehyde.Itmaybegenerated
byboilingcommercialformalinin2volumesofwater(500
miofformalinplus
1litreofwaterper30cu.metresof
space)inastainlesssteelvessel,overanelectrichotplateor
byaddingpotassiumpermanganatetocommercialformalin
inlargejars(170-200gramto500mlofformalinplus
1litre
ofwaterper30cu.metres)(152).Thereisvigorousboiling
andliberationofformaldehydegas.Theroomiskeptclosed
for6-12hourstoallowdisinfection.Formaldehyde
disintectionismosteffectiveatahightemperatureanda
relativehumidityof80-90percent.
Startcleaningfromcleanerareasandproceedtowards
dirtierareas.
Allindoorareassuchasentrancelobbies,corridorsand
staircases,escalators,elevators,securityguardbooths,
ofticerooms,meetingrooms,cafeteriashouldbe
moppedwithadisinfectentwith1%sodiumhypochlorite
orphenolicdisinfectants.
Highcontactsurfacessuchaselevatorbuttons,
handrails/handlesandcallbuttons,escalatorhandrails,
publiccounters,intercomsystems,equipmentlike
telephone,printers/scanners,andotherofficemachines
shouldbecleanedtwicedailybymoppingwithalinen
absorbableclothsoakedin1%sodiumhypochloride.
Frequentiytouchedareasliketabletops,chairhandles,
pens,diaryfiles,keyboards,mouse,mousepad,tea'
coffeedispensingmachinesetc.shouldspeciallybe
cleaned.
SpecialDisinfectionProcedures
(InCOVID-19context)
Sanitizationtunnel
Itisatunnelorgatewayforthesanitizationand
decontaminationofitemsandpeoplewhencombinedwith
appropriatelyatomizedbiocidesand/orvirucidespray.
Thesesanitaryanddecontaminationtunnelsandgates
representasafeprotectionandentryforeveryone,in
particularforthosewhoworkinclosecontactwithgroups
andarethereforeathigherrisk.Itcanbeinstalledatthe
entranceofpublicoffices,pharmacies,supermarkets,
airports,hospitals,ports,stationsandtorcompanieswho
needtosanitizetheworkforce,goods,vehiclesand
materials.
Thetunnelcreatesanobligatorypassageandisequipped
withinternalarc-snapedatomizingnozzlesthatsaturatethe
environment.Thenebulizationsystemisconnectedto
controlsystemcapableofautomaticallymixingand
sanitizingproductsatpercentageindicatedbythe
manufacturer.Theliquidissprayedintheformofmistfor
6-8secondsonthepersonwalkingthroughthetunnel.
Accesstothetunnelisregulatedbyatrafficlightwith
motiondetection.
Byplacingabarrierfloorinsidethe
sanitarygate,itispossibletosanitizethesurfaceincontact
withtheground.
The
chemicalused
isa
hydrogenperoxideànd
isopropylalcoholwithdistilledwater;(b)sodiumn
hypochlorite1ormaterialsanitization;(c)sodium
hypochloriteforhumansunderPPEprotection;and
(d)concentratedchemicalfreeandalcoholfreeayurvedic
solutionwithenriched100percentsilvernanoparticles.
Formetallicsurfaceslikedoorhandles,securitylocks,
keysetc.,70%alcoholcanbeusedtowipedown
surtaceswheretheuseofbleachisnotsuitable.
Handsanitizingstationsshouldbeinstalledinottice
premises(speciallyattheentry)andnearhighcontat
surfaces.
Inameeting/conference/officeroom,if
someone
coughing,withoutfollowingrespiratoryetiquetes
o
mask,theareasaroundhis/herseatshouldbevacateu
andcleanedwith1%sodiumhypochlorite.
Carefullycleantheequipmentusedincleaning9
endofthecleaningprocess.
the
and
Remove PPE,discardinayellowdisposablebag
washhandswithsoapandwater.
he
Inaddition,allemployeesshouldconsidercleanin
workareainfrontofthemwithadisintectingwipe
useandsitoneseatfurtherawayfromothers,itp0s5i
2.Outdoorareas
Outdoorareashavelessriskthenindoorareas
$top
urrentsandexposuretosunlight.Theseincludebussnd
railwayplatforms,park,roads,etc.Cleanihed
disinfectionefortsshouldbetargetedtofrequentlytou
contaminatedsurfacesasalreadydetailedabove.
due
toai
iti

15. 145
SPECIAL.DISINFECTION
PROCEDURE
3.
Publictoilets
hitaryworkersmustuseseparatesetofcleaning
tnmentfortoilets(mops,nylonscrubber)andseperate
cotforsinkandcommode).Theyshouldalwau
dienosableprotectivegloveswhilecleaningatoilet.
Guidelinesforpreparationof1%sodium
hypochloritesolution
|Product 1percentsolution
Availablechlorine
1partbleachto
2.5partswater
Sodiumhypochlorite
-liquidbleach
Sodiumhypochlorite5%
-liquid
NaDCC(sodium
dichloro-isocyanurate)
|
powder
NaDCC(1.5g/tablet)
tablets
Chloramine
-
powder25%
Bleachingpowder
Anyother
3.5%
1partbleachto
4partswater
17gramsto
1litrewater
Agents
Toiletcleaner
Areas Procedure
60%
Toiletpot/SodiumhypochloriteInsideoftoiletpot/commode:
commode
1%/detergent Scrubwiththerecommended
agentsandthelonghandle
angularbrush.
Outside:cleanwith
Soappowder/long
handleangularbrush
11tabletsto
1litrewater
60%
80gto
1litrewater
recommendedagents;
useascrubber. 7gto
1litrewater
70%
Aspermanufacturer'sInstructions
Wetandscrubwithsoap
powderandthenylon
scrubberinsideandoutside.
Wipewith1%Sodium
Hypochlorite.
NylonscrubberLid
commodeandsoap
4.PersonalProtectiveEquipment(PPE)
powder/detergent
1%Sodium WearappropriatePPEwhichwouldincludethefollowing
whilecarryingoutcleaninganddisinfectionwork.
Weardisposablerubberboots,gloves(heavyduty),and
atriplelayermask
Hypochlorite
ToiletfloorSoappowder/
detergentand
scrubbingbrush
nylonbroom1%
SodiumHypochlorite
.Scrubfloorwithsoappowder
andthescrubbingbrush
Washwithwater
.Usesodiumhypochlorite
1%dilution.
Glovesshouldberemovedanddiscarded/damaged,and
anewpairworn.
AlldisposablePPEshouldberemovedanddiscarded
aftercleaningactivitiesarecompleted.
Handsshouldbewashedwithsoapandwater
immediatelyaftereachpieceofPPEisremoved,
followingcompletionofcleaning.
Masksareeffectiveifwornaccordingtoinstructionsand
properlyfitted.Masksshouldbediscardedandchangedif
theybecomephysicallydamagedorsoaked.
Soappowder/
detergentand
nylonscrubber1%
SodiumHypochlorite
Scrubwiththenylon
scrubber.
Sink
Wipewith1%sodium
hypochlorite.
Thoroughlyscrubthefloors/
tileswithwarmwaterand
Showers Warmwater,
Detergentpowder
TapsandNylonScrubber
1%Sodium
Hypochlorite
70%alcohol
area
detergent.
Wipeovertapsandfittings
withadampclothand
detergent.
Careshouldbetakentoclean
theundersideoftapsand
fittings.
Wipewith1%sodium
hypochlorite/70%alcohol
fittings
Handwashingtechnique
Fig.26showsstepsofhandwashingtechniquewithsoap
andwater(156).
SoapDetergentand
dispenserSwater
Shouldbecleaneddailywith
detergentandwaterand
dried.i
Wethands Applyenoughsoapto
Coverallhandsurtaces
Rubhands
paimtopalm
Rubbackoteachhand
withpalmofotherhand
withfingersinterlocked
withwater
0%
Alcoholcanbeusedtowipedownsurfaceswherethe
use
ofbleachisnotsuitable,e.g.metal:Chloroxylenol(4.5-5.5%)|
BenzalkoniumChlorideor
any
otherdisinfectantsfoundtobe
etectiveagainstcoronavirus
maybeusedas
per
manufacturer's
instructions.
Alwaysusefreshlyprepared1%sodiumhypochlorite.
RubpalmtopalmwithRubwithbackoffingersRubeachthumbclaspedRubtipsoffingersin
tingersinterlockedtoopposingpalmswithnoppsitehandusingaoppositepalmina
fingersinterlocked
rotationalmovement
Circularmotion
DOnot
use
disinfectantssprayonpotentiallyhighly
contaminatedareas(suchastoiletbowlorsurrounding
Surfaces)as
it
may
createsplasheswhichcanfurther
spreadthevirus.
Rubeachwristwith
oppositehand
Rinsehands Useelbowto
turnofftap
Drythoroughlywitha
Single-usetowel
water
lo
preventcrosscontamination,discardcleaning
materialmadeofcloth(mopandwipingcloth)in
ppropriatebagsaftercleaninganddisinfecting.Wear
ew.pairofgloveandfastenthebag,e1
sinfectall,cleaningequipmentafteruse
andbefore
usingi
otherareas.
isinfectbucketsbusoakinginbleachsolutionorrinsein
hotwater
Handwashingshould
take15-30seconds
FIG.26
Handwashingtechniquewithsoapandwater

16. 46
PRINCIPLESOFEPIDEMIOLOGYANDEPIDEMIOLOGICMETHODS
Guidelinesforuseofmask(156) maybespurious,andarisefrommisinterpretationofsin
andsymptomsbythelaypublic.Itisthereforenecessaryto
havetheverificationofdiagnoSisonthespot,asquickly
as
possible.Itisnotnecessarytoexamineallthecasestoarrivo
atadiagnosis.Aclinicalexaminationofasampleof
cases
maywelsuffice.Laboratoryinvestigationswherever
applicable,aremostusefultoconfirmthediagnosisbutthe
epidemiologicalinvestigationsshouldnotbedelayedunti
thelaboratoryresultsareavailable.
Thecorrectprocedureofwearingtriplelayersurgical
maskisasfollows:
1.Performhandhygiene
2.Unfoldthepleats;makesurethattheyarefacingdown.
3.Placeovernose,mouthandchin.
4.Fitflexiblenosepieceovernosebridge.
5.Securewithtiestrings(upperstringtobetiedontopot
headabovetheearslowerstringatthebackofthe
neck.)
6.Ensuretherearenogapsoneithersideofthemask,
adjusttofit.
7.Donotletthemaskhangingfromtheneck.
8.Changethemaskaftersixhoursorassoonasthey
2.Confirmationoftheexistenceofanepidemic
Thenextstepistoconfirmifepidemicexists.Thisisdone
bycomparingthediseasefrequenciesduringthesame
periodotpreviousyears.Anepidemicissaidtoexistwhen
thenumberofcases(observedfrequency)isinexcessofthe
expectedtrequencytorthatpopulation,basedonpast
experience.Anarbitrarylimitoftwostandarderrorsfrom
theendemicoccurrenceisusedtodefinetheepidemic
thresholdforcommondiseasessuchasintluenza(3).Often
theexistenceofanepidemicisobviousneedingnosuch
comparison,asinthecaseofcommon-sour
cholera,foodpoisoningandhepatitisA.Theseepidemics
becomewet.
9.Disposablemasksarenevertobereusedandshouldbe
disposedoff.
10.Whileremovingthemaskgreatcaremustbetakennot
totouchthepotentialyinfectedoutersurfaceofthe
mask.
epidemicsof
11.Toremovemaskfirstuntiethestringbelowandthenthe
stringaboveandhandlethemaskusingtheupper
strings.
12.Disposalofusedmasks:Usedmaskshouldbeconsidered
aspotentiallyinfectedmedicalwaste.Discardthemask
inaclosedbinimmediatelyafteruse.
areeasilyrecognized.Incontrasttheexistenceofmodern
epidemics(e.g,cancer,cardiovasculardiseases)isnoteasily
recognizedunlesscomparisonismadewithprevious
experience
3.Definingthepopulationat-risk
INVESTIGATIONOFANEPIDEMIC
(a)Obtainingamapofthearea:Beforebeginningthe
investigation,itisnecessarytohaveadetailedandcurrent
Theoccurrenceofanepidemicalwayssignalssome
significantshiftintheexistingbalancebetweentheagent,
hostandenvironment.Itcallsforapromptandthorough
investigationofthecasestouncoverthefactor(s)
responsibleandtoguideinadvocatingcontrolmeasuresto
preventturtherspread.Emergenciescausedbyepidemics
mapofthearea.Ifthisisnotavailable,itmaybenecessary
topreparesucha
map.Itshouldcontaininformation
oncerningnaturallandmarks,roadsandthelocationotall
dwellingunitsalongeachroadorinisolatedareas.Thearea
maybedividedintosegments,usingnaturallandmarkSas
oundaries.Thismayagainbedividedintosmallersections.
Withineachsection,thedwellingunits(houses)maybe
lesignatedbynumbers.
remainoneofthemostimportantchallengestonational
healthadministrations.Epidemiologyhasanimportantrole
toplayintheinvestigationofepidemics.Theobjectivesof
anepidemicinvestigationare(3,22,153).
(b)Countingthepopulation:Thedenominatormaybe
elated
tOtheentirepopulationorsub-groups
or
apopulation.Itmayalsoberelatedtototalevents(see
age45formoredetails).Forexample,ifthedenominatoris
neentrepopulationacompletecensusofthepopulation
byageandsexshouldbecarriedoutinthedefinedareaby
ouse-to-housevisits.Forthispurposelayhealthworkers
insufficientnumbersmaybeemployed.Usingthis
techniqueitispossibletoestablishthesizeofthe
population.Thepopulationcensuswillhelpincomputing
themuch-neededattackratesinvariousgroupsand
subgroupsofthepopulationlateron.Withoutan
ppropriatedenominatorof"populationatrisk"attackrates
cannotbecalculated.
a.todefinethemagnitudeoftheepidemicoutbreakor
involvementintermsoftime,placeandperson.
b.todeterminetheparticularconditionsandfactors
responsibletortheocCurrenceoftheepidemic.
toidentitythecause,source(s)ofinfection,and
modesottransmissiontodeterminemeasures
necessarytocontroltheepidemic;and
d.tomakerecommendationstopreventrecurrence.
Anepidemicinvestigationcallsforinferenceaswellas
description.Frequently,epidemicinvestigationsarecalled
forafterthepeakoftheepidemichasoccurred;insuch
cases,theinvestigationismainlyretrospective.Nostepby
stepapproachapplicableinallsituationscanbedescribed
likea"cook-book"(153).However,ininvestigatingan
epidemic,itisdesiredtohaveanorderlyprocedureor
practicalguidelinesasoutlinedbelowwhichareapplicable
foralmostanyepidemicstudy.Someofthestepscanbe
doneconcurrently.
4.Rapidsearchforallcasesandtheir
characteristics
(a)Medicalsurvey:Concurrently,amedicalsurvey
shouldbecarriedoutinthedefinedareatoidentifyallcase
includingthosewhohavenotsoughtmedicalcare,and
thosepossiblyexposedtorisk.ldeally,thecompletesurvey
(screeningeachmemberofthepopulationforthepresenC
ofthediseaseinquestion)willpickupallaffected
individualswithsymptomsorsignsofthedisorder.Lay
1.Verificationofdiagnosis
Verificationofdiagnosisisthefirststepinanepidemic
investigation,as
itmayhappensometimesthatthereport

17. MEASILES
However,
admínistrationofaseconddoseis
recommended
Torexposedpeopletobríngthem
up-to-dateonvaccination
andforbestprotectionagainst
future
exposure(9
Severalunresolvedissuesremain,
includingtheneedfor
boosterdoses,whetheruniversalchildhood
vaccinationwil
shifttheincidenceofdiseasetoadolescenceoradulthood
Withthepossibilityofmoreseveredisease,andwhether
vaccinafionmightpreventdevelopmentofherpeszoster.
5
units/kgbodyweightuptoamaximumof625units,
repeatdosein.3weeks,ifahigh-riskpalientremains
wied.
BecauseVZIGappearstobindthevaricellavacine,
wo
shouldnotbegivenconcomitantly(4).
2.
VACCINE
Alive
attenuatedvaricellavirusvaccineissafeand
ntlu
recommendedforchildrenbetween12-18months
ofagewhohavenothadchickenpox.
Rocommendationsondosageandintervalbetweendoses
arv
bymanuiacturer.Monovalentvaccinecanbe
administeredfollowingoneortwodoseschedule(0.5ml
oach
bysubcutaneousinjection.A2dosescheduleis
rocommendedforallpersonsaged213years.When2doses
are
administered,theminimumintervalbetweendosesis
from
4weeksto3monthsforchildren(12monthsto
12vearsofageinclusive),and4or6weeksforadolescents
andadults(13yearsofageandolder).
Combinationvaccines(MMRV)canbeadministeredto
childrenfrom9monthsto12years.It2dosesofMMRVare
used,theminimumintervalbetweendosesshouldbe
4weeks.Itispreferredthatthe2nddosebeadministered
6weeksto3monthsafterthefirstdoseorat4-6yearsof
age(2).
Thedurationofimmunityisnotknownbutisprobably10
years.Althoughthevaccineisveryeifectiveinpreventing
disease,breakthroughinfectionsdooccurbutaremuch
milderthaninunvaccinatedindividuals(usuallylessthan50
lesions,withmildersystemicsymptoms).Althoughthe
vaccine
isverysafe,adversereactionscanoccuraslateas
4-6weeksaftervaccination.Tendernessanderythemaatthe
injectionsiteareseenin25%,feverin10-15%,anda
localizedmaculopapularorvesicularrashin5%;asmaller
percentagedevelopsadiffuserash,usuallywithfiveorfewer
vesicularlesions.
References
1Jawetz,
MelnickandAdelberg's
MedicalMicrobiology.(2007).24th
Ed.,ALangePublication.
2.WHO(2014),Weekly
EpidemiologicalRecord,No.25.June20.2014
3.Govt.ofIndia(2019),NationalHealthProfileofIndia2019,Ministry
ofHealthandFamilyWelfare,NewDelhi.
4.Lawrence,M.,Tierney,Jr.(2008).CurrentMedicalDiagnosisand
freatment,(2008),47thEd.,ALangePublication.
5.Weller,ThomasH.(1977).inViralInfectionsofHumans
EpidemiologyandControl,EvansAlfred,S.etal{eds).2nded.
PlenumMedical,NewYork.
6.Christie,A.B.(1980).InfectiousDiseases:EpidemiologyandClinical
Practice,3rded.,ChurchilLivingstone.
7.Stephen,
RPrebludandA.R.Hinman(1980).Maxcy-Rosenau:Public
HealthandPreventiveMedicine,Last.J.M.(ed),11thed.Appieton-
Century-Crofts.
8
WHO(1985)BulIWHO63:433.
9.CDCPinkBook(2019),EpidemiologyandPreventionofVaccine
PreventableDiseases.
10.WHO(1985)Techn.Rep.Ser..No.725.
11.Bres,P:
(1986)PublicHealthActioninEmergenciescausedby
Epidemics.Geneva,WHO.
MEASLES
(RUBEOLA)
Anacutehighlyinfectiousdiseaseofchildhoodcausedby
aspecificvirusofthegroupmyxoviruses.
Itisclinicaliy
characterizedbyfeverandcatarrhalsymptomsoftheupper
respiratorytract(coryza,cough),followedbyatypicalrash.
Measlesisassociatedwithhighmorbidityandmortalityin
developingcountries.Measlesoccursonlyinhumans.There
isnoanimalreservoirofinfection.
Spreadofvirusfromvaccineestosusceptibleindividuals
ispossible,buttheriskofsuchtransmissionevento
immuno-compromisedpatientsissmall,anddisease,whenit
develops,ismildandtreatablewithacyclovir.Nonetheless,
thevaccine,beingaliveattenuatedvirus,shouldnotbe
givento
immunocompromisedindividuals.Theuseof
varicellavaccinemaybeconsideredinclinicallystableHIv.
iniectedchildrenoradultswithCD4+T-celllevels215per
centincludingthosereceivinghighlyactiveantiretroviral
LnerapyHIVtesting.isnotaprerequisiteforvaricella
Vaccination(2).It
iscontraindicatedinpersonsallergicto
neomycinFortheoreticreasons,itisrecommendedthat
1O1lowingvaccination,salicylatesshouldbeavoidedfor6
weeks(topreventReye'ssyndrome).
Problemstatement
Measlesisendemicvirtuallyinallpartsoftheworld.It
tendstooccurinepidemicswhentheproportionof
susceptiblechildrenreachesabout40percent(1).Whenthe
diseaseisintroducedintoavirgincommunitymorethan90
percentofthatcommunitywillbeinfected(2).While
measlesisnowrareinindustrializedcountries,it
remainsa
commonilnessinmanydevelopingcountries.Theprimary
reasonforcontinuinghighchildhoodmeaslesmortalityand
morbidityisthefailuretodeliveratleastonedoseof
measlesvaccinetoallinfants(3).
Thechallengesformeasleseliminationinclude(1)weak
immunizationsystems;(2)highinfectiousnatureofmeasles;
(3)populationsthatareinaccessibleduetoconflict;(4)the
increasingrefusalotimmunizationbysomepopulations;
(5)thechangingepidemiologyofmeasleswhichhasledto
increasedtransmissionamongadolescentsandadults;
(6)theneedtoprovidecatch-upmeaslesvaccinationto>130
millionchildreninIndia;(7)the
gapsinhumanandfinancial
resourcesatthecountry,regionalandgloballevels(4).
In1980,beforewidespreaduseofmeaslesvaccine,an
estimated2.6millionmeaslesdeathsoccurredworldwide.
Recognizingthisburden,WHOandUNICEFdevelopedan
acceleratedmeaslesmortalityreductionstrategyof
Varicellavaccinationiscontraindicatedduringpregnancy
onpregnancyshouldbedelayedfor4wèeksafter
eination.Terminationofpregnancyisnotindicated
Vaccination
wascarriedoutinadvertentlyduring
pregnancy
(9)
POST-EXPOSUREPROPHYLAXIS
VccineVaricellavaccineis
recommended
1orpost
OSUreadministrationtoun-vaccinatedhealthypeople
Zmonthsandwithoutotherevidenceofimmunity,to
nt
ormodifythedisease.Thevaccineshouldbe
to
adminis
as
soonaspossiblewithin5daysafterexposure
Chilathereis
nocontraindicationtouse.Among
protective
efficacy.wasreported
as290percent
accinationoccurredwithin3:daysof
exposure.

18. 162
EPHEMIO1OGY OFCOMMUNICABLE MSEASES
delivering2dosesofmenslescontainingvaccine(MCV)to
allchildenthroughroutineservicesandsupplementary
immunizingactivities(SIAs).andimprovingdisease
Surveillancec.Inplementationofthisstrategybeganin2001
Althe2010WorldHealtlhAssembly,memberstates
chdorsedthetollowingtargelstobemetby2015as
mitestonestowardseventualglobalmeasleseradication:ol
rasnmorethancoverstheperiodof
fro
(1)raiseroutinecoveragewiththefirstdoseofMCV(MCV,)
to290percentnationally,and280percentineverydistrict
orcquivalentadministrativeunit;(2)reduceandmaintain
annualmeaslesincidenceto<5casespermillion;and
(3)reducemeaslesmorlalityby295percentincomparison
withthecstimatedlevelintheyear2000(5).
earlystagesoftherash.(d}COMMUNIC A
highlyinfectiousduringtheprodromaln
Y
oferuption.Communicability
deciian
appearanceottherash.The
period
approximately4daysbeforeand4dausaf
oftherash.Isolationofthepatientforahe
(e)SECONDATTACKRATE:Ther
tsonty
ne
typeofmeaslesvirus.Intection
confers
ifeiMostso-calledsecondattacksrepresentorr
eitherininitialorsecondillness(10)
ertors
Hostfactors
TheGlobalMeaslesandRubellaStrategicPlan2012-20
periodsawasignificantreductioninthemeaslesandrubella
diseaseburden.asteepincreaseintheintroductionofadevelopingcountrieswhereenvironme
(a)AGE
childhood
-
between6months
and3
Affects
virtuallyeveryone
in
ia
vaccines,andimprovementsinsurveillance.During2018,
approximately346millionpeoplereceivedmeasles
vaccinationthrough45supplementaryimmunization
activities(SlAs)in37countries.Estimatedmeasles-related
deathsdeclinedby73percentandestimatedcasesby76per
centfrom2000to2018.Itstillaccountedforanestimated
Seconddoseofmeasles-containing(MCV,)andrubellagenerallypoor,andolderchildrenustaltnd
developedcountries(11).Followingthee
vaccine,thediseaseisnoWseenin
somewhatrl
groups(12).Thishighlightstheimportanceot
serologicalcheckingoftheimmunity
Status
Incidence
(c)IMMUNITY :Noageisimmuneit
therewas
no
immunity.Oneattackotmeaslesgenerallyconfers
immunity.Secondattacksarerare.intantsareprote
maternalantibodiesuptobmonthsofage:in
maternalimmunitymaypersistbeyondmonths.In
aftervaccinationIsquitesolidandlcng-a
(d)NUTRITION :Measlestendstobevery
severe
malnourishedchild,carryingamortalityupto
40 a
higherthaninwell-nourishedchildrenhaving
meas
Thismaypossiblyberelatedtopoorceil-mediated
i
Tesponse,secondarytomalnutrition(141.Atdi
severelymalnourishedchildrenhavebeenshownto
measlesvirusforlongerperiodsthanberter
0
childrenindicatingprolongedrisktothemseives.
intensityofspreadtoothers(15).Evenina
heatny
attackofseveremeaslesmaybefollowedbyWe
susceptiblepopulation.(b)SEX
9.7millioncasesandmorethan140,000measlesrelated
deathsworldwideduring2018(6).Measlesisresponsiblefor
about2percentofunder-fivemortalityworldwide(8).
InIndia.measlesisa
significantcauseofchildhood
morbidity.Priortotheimmunizationprogramme,cyclical
increaseintheincidenceofmeasleswererecordedevery
thirdyear.Withtheincreaseinimmunizationcoverage
levels,theintervalsbetweencyclicalpeakshasincreasedand
theintensityofthepeakminimized.However,several
outbreaksarereportedintribalandremoteareas.The
retrospectivedataindicateadecliningtrendofmeaslesin
thecountry.During1987about2.47lakhcaseswere
reported,whereas,atterimplementationofOIP,thenumber
ofcaseshascomedownto20,895with34deathsduringthe
year2018.
precipitatingthechildintomalnutrition.
ThestatesmajorlyaffectedwereWestBengal(4,886
casesand8deaths),Assam(2,361cases),JammuandEnvironmentalfactors
Kashmir(2,039cases),Maharashtra(1,963casesand2
deaths),Delhi(1,371casesand12deaths),UttarPradesh
(1,349cases),andRajasthan(1,067casesand3deaths)(7).
Thecountryismakingsignificantprogresstowardsthegoal
ofmeasleseliminationandrubella/congenitalrubella
syndromecontrol.Thestrategiesformeaslesandrubella
eliminationinclude:(1)95percentcoveragewithmeasles
andrubellavaccination;(2)Case-basedmeasles-rubella
surveillancewithadequatelaboratorysupport;(3)Linkage
withotherchildhealthinterventions;and(4)Increased
publicconfidenceanddemandforimmunization(8).
seaso
Givenachance,theviruscanspreadin
ang
Intropicalzones,mostcasesotmeaslesOCcur
Curng
season.Intemperateclimates.measlesis
à
nter
probablybecausepeoplecrowdtogetherindoct.
Ormeaslesarecommoninndiaduringwin
springfJanuarytoApril).Population
denstu
mN
aoalectepidemicity(16).Ingeneral,thelesst
prevailingsocio-economicconditions,
tnetow
ageatwhichchildrenareattacked.
Transmission
Epidemiologicaldeterminants
erson®
Transmissionoccursdirectlytrom
mainlybydropletinfectionanddropletn
nuclei,ro
Deloreonsetofrashuntil4daysthereartei
entryistherespiratorytract.Intectiontntilled
alsoconsideredlikelyasthevirus.nts
of
COnjunctivacancauseinfection.Recp
vaccinearenotcontagioustootheTstt
Agentfactors
(a)AGENT:MeaslesiscausedbyanRNAparamyxovirus.
Sofarasisknown.1hereisonlyoneserotype.Thevirus
cannotsurviveoutsidethehumanbodyforanylengthof
time,butretainsinfectivitywhenstoredatsub-zero
temperature.Thevirushasbeengrownincellcultures.
(b)SOURCEOFINFECTION:Theolysourceofinfectionis
acaseofmeasles.CarriersarenotknowntoOccur.Thereis
someevidencetosuggestthatsubclinicalmeaslesoccurs
moreoftenthanpreviouslythought.(c)INFECTIVE
MATERIAL:Secretionsofthenose,throatandrespiratory
tractofacaseofmeaslesduringtheprodromalperiodandthe
ne
prs
Incubationperiod
Incubationperiodiscommonly
nceof
onsetoffever,and14daystoapped
ays
trom
enp
measlesinfectionisartificiallyeasles
espiratorytract(aswithinjectionoflivaerag
Oypass
ncubationperiodissomewhatshortene

19. 164
EPIDEMIOLOGY OFCOMMUNICABLE DISEASES
Preventionofmeasles aDTP-containingbooster,PCV
Thefollowingguidelinesareimportantincombating
measles:
(forexample,
meningococcalvaccines).Thismeasurealsosupporte
establishmentofapolicyonimmunizationandotherheals
interventionsinthesecondyearoflife.IfMCV,
coverar
ge
a.achievinganimmunizationrateofover95percent,
and
high(>90%)andschoolenrolmentishigh(>95%
administrationofroutineMCV,atschoolentrymayprov
aneffectivestrategyforachievinghighcoverageand
preventingoutbreaksinschools(22).
MCVadministeredbefore9monthsofageshouldbe
consideredasupplementarydoseandrecordedon
the
child'svaccinationrecorda
b.on-goingimmunizationagainstmeaslesthrough
Successivegenerationsofchildren.
1.Measlesvaccination
hildrenwhoreceive
Measlesisbestpreventedbyactiveimmunization.
VACCINE Onlyliveattenuatedvaccinesare
recommendedforuse;theyarebothsafeandeffective,and
maybeusedinterchangeablywithinimmunization
programmes.Persontopersontransmissionofmeasles
MCV"
MCV,shouldalsoreceiveMCV,andMCV,at
recommendedagesaccordingtothenationalschedule.
A
supplementarydoseofMCVshouldbegiventoinfantsfrom
6monthsofage
:(1)duringameaslesoutbreakaspartof
intensifiedservicedelivery;(2)duringcampaignsinsettings
wheretheriskofmeaslesamonginfants<9monthsof
age
remainshigh(e.g.inendemiccountriesexperiencingregular
outbreaks);(3)forinternallydisplacedpopulationsand
refugees,andpopulationsincontlictzones;(4)forindividual
infantsathighriskofcontractingmeasles(e.g.contactsof
knownmeaslescasesorinsettingswithincreasedriskof
exposureduringoutbreakssuchasday-carefacilities;
(5)forinfantstravellingtocountriesexperiencing
measles
outbreaks;(6)forinfantsknowntobeHIV-infectedor
exposed(i.e.borntoanHIV-infectedwoman)(22).
the
vaccinestrainshasneverbeendocumented.Thevaccineis
presentedasafreeze-driedproduct.Beforeuse,the
lyophilizedvaccineisreconstitutedwithsterilediluent.Each
doseof0.5mlcontains21000viralinfectiveunitsofthe
vaccinestrain;thisisalsotruewhenitispresentedasan
MCVcombination.Measlesvaccinemayalsocontain
sorbitolandhydrolysedgelatinasstabilizers,aswellasa
smallamountofneomycin,butitdoesnotcontain
thiomersal.Ingeneral,itisrecommendedthatfreeze-dried
vaccinebestoredinarefrigeratedcondition(20).The
diluentmustnotbefrozenbutshouldbecooledbefore
GiventheseverecourseofmeaslesinpatientswithAIDS,
measlesvaccinationshouldberoutinelyadministeredto
potentiallysusceptible,asymptomaticHIVinfectedchildren
andadults.Vaccinationmayevenbeconsideredforthose
withsymptomaticHIVinfectioniftheyarenotseverely
immuno-suppressedaccordingtoconventionaldefinitions.
InareaswherethereisahighincidenceofbothHIV
infectionandmeasles,aninitialdoseofMCVmaybe
offeredasearlyasage6months(recordedasMCV).The2
routinedosesofMCV(MCV,andMCV,)shouldthenbe
administeredtothesechildrenaccordingtothenational
immunizationschedule(22).
reconstitution.Reconstitutedmeaslesvaccinelosesabout
50percentofitspotencyafter
1
hourat20°C;itloses
almostallpotencyafter
1
hourat37°C.Thevaccineisalso
sensitivetosunlight,henceitiskeptincolouredglassvials.
Afterreconstitution,thevaccinemustbestoredinthedark
at2-8°Candusedwithin4hours.
Measlesvaccineisavailableinmonovalent(measlesonly)
formandincombination
:measles-rubella(MR),measles-
mumps-rubella(MMR)vaccine,andmeasles-mumps-
rubella-varicella(MMRV)vaccine.
Reachingallchildrenwith2dosesofmeaslescontaining
vaccine(MCV)shouldbethestandardforallnational
immunizationprogrammes.Incountrieswithongoing
transmissioninwhichtheriskofmeaslesmortalityremains
high,MCV,shouldbegivenatage9months.MCV,should
begivenbetween15-18months,asprovidingMCV,inthe
2ndyearoflifereducestherateofaccumulationof
susceptiblechildrenandtheriskofanoutbreak.The
minimumintervalbetweenMCV,andMCV,is4weeks.
Everyopportunity(e.g.whenchildrencomeintocontact
withhealthservices)shouldbetakentovaccinateall
childrenthatmissedoneorbothMCVroutinedoses,
particularlythoseunder15yearsofage.Policieswhich
prohibituseofvaccineinchildren>1yearofage,older
childrenandteenagersshouldbechangedtoallowthese
individualstobevaccinated.
CONTRAINDICATIONS TOVACCINATION(23)MMR
andothermeasles-containingvaccines
notare
recommendedforHIV-infectedpersonswithevidence
of
severeimmunosuppression.MMRVisnotapprovedforand
shouldnotbeadministeredtoapersonknowntobeinfected
withHIV.
Personswithmoderateorsevereacuteillnessshouldnot
bevaccinateduntilthepatienthasimproved.This
precautionisintendedtopreventcomplicatingthe
managementofanillpatientwithapotentialvaccine
adversereaction,suchasfever.Minorillness(e.g.,otitis
media,mildupperrespiratoryinfections),concurrent
antibiotictherapy,andexposuretoorrecoveryfromother
illnessarenotcontraindicationstomeaslesvaccination.
Receiptof
(e.g.,immuneglobulin,wholebloodorpackedredblood
cells,intravenousimmuneglobulin)mayinterferewitn
sero-conversionaftermeaslesvaccine.Thelengthoftime
thatsuchpassivelyacquiredantibodypersistsdepends
on
theconcentrationandquantityofbloodproduct
received,
Forinstance,itisrecommendedthatvaccinationbedelayea
tor3monthsfollowingreceiptofimmuneglobulin1o
prophylaxisofhepatitisA;a7to11monthsdelay5
recommendedfollowingadministrationof
intravenous
immuneglobulin,dependingonthedose.
antibody-containing
Incountrieswithlowlevelsofmeaslestransmission
(i.e.thosethatareneareliminationorverifiedashaving
eliminatedendemicmeaslesvirustransmission),and
thereforetheriskofmeaslesvirusinfectionamonginfantsis
low,MCV,maybeadministeredat12monthsofagetotake
advantageofthehighersero-conversionratesachievedat
thisage.Inthesecountries,theoptimalagefordelivering
MCV,isbasedonprogrammaticconsiderationstoachieve
thehighestcoverageofMCV,and,hence,thehighest
populationimmunity.AdministrationofMCv,at15-18
months.ofageensuresearlyprotectionoftheindividual,
slowsaccumulationofsusceptibleyoungchildren,andmay
correspondtothescheduleforotherroutineimmunizations
bloodproducts
iReplicationofvaccinevirusescanbeprolonged
personswhoareimmunosuppressedorimmunodeficien

20. MEASI.ES 165
3-4daysofexposure.Thepersonpassivelyimmunized
shouldbegivenlivemeaslesvaccine8-12weekslater.The
needforimmunoglobulinisnowmuchreducedsecauseof
theavailabilityofaneffectiveliveattenuatedvaccine.
overeimmunosuppressioncanbeduetoavarietyof
onditions.inclidingcongenitalimmunodeficiency,HIV
oction.leukaemia,Iymphoma,generalizedmalignancy,or
orapU
withalkylatingagents,antimetabolites,radiation,or
rgedosesolcorticostleroids.Forthisreason,personswho
reseverelyimmunocom
egivenmeaslescontainingvaccine.
Womenknowntobepregnantshouldnotreceivemeasles
vaccine.Pregnancyshouldbeavoidedfor4weeksfollowing
MMRvaccine.Closecontactwithapregnantwomanisnota
ontraindicationtoMMKvaccinationofthecontact.
Breastfeedingisnotacontraindicationtovaccinationof
eitherthewomanorabreastfeedingchild.
Dotuberculinskintesting(TST)atthesamevisitasMMR
vaccination.ordelay1TSTatleast4weeksifMMRisgiven
first.TheleastfavouredoptionistodoTSTfirstand
administerMMRWhens
isreadasitdelaysthe
vaccination.TSThasnoeffectontheresponsetoMMR
vaccination.However,measlescontainingvaccinesmay
transientlysuppressthe
responsetoTSTinapersoninfected
withM.tuberculosis(23).
Oised
1oranyreasonshouldnotGIobalmenslesandrubellastrategicframework
2021-2030(MRSF)(6)
Themeaslesandrubellastrategicframework2021-2030
aimstoprovideahigh-levelframeworkthatwillguídethe
regionalandnationalstrategiesandoperationaiplans.
withintheumbrellaoftheImmunizationAgenda239
structure.Itaimstoestablishconvergencewithotherkey
agencystrategydocuments.
Itenvisions"Aworldfreefrom
measlesandrubella".Thegoalforthe2021-2030periodis
toachieveandsustaintheregionalmeaslesandrubella
eliminationgoals".
Thecorestrategiesidentifiedinthe2012-20MRSPwil
remainrelevantinthepost2020period.Thestrategic
prioritiesareasfollows
1.Incorporateallmeaslesandrubellaactivities,including
surveillanceandcasemanagement,askeycomponents
ofeftectivePHCsysteminsupportofuniversalheaith
ADMINISTRATION:Thereconstitutedvaccineis
generallyinjectedSubcutaneously,but
itisalsoeffective
whenadministeredintramuscularly.
REACTIONS Wheninjectedintothebody,the
attenuatedvirusmultipliesandinducesamild"measles
illness(feverandrash)5to10daysafterimmunization,but
inreducedfrequencyandseverity.Thismayoccurin15to
20percentofvaccinees.Thetevermaylastfor1-2days
andtherashfor1-3days.Thereisnocauseforalarm.he
vaccinesnowgivenrarelycauseseverereaction(10).There
coverage.
2.Improveownershipandaccountabilityotmeaslesand
rubellagoalsandtargetsatallleveisandimprove
communitydemandforuptakeofmeaslesandrubella
containingvaccines.
3.ldentifyandcloseimmunitygapstomeaslesandrubella
byettectivelyutilizing
alllrelevantcontactsberwean
individualsandthehealthsystem.establishingo
strengtheningnewcontactpointswhererequired.annd
using
targetedapproachestoreachunder-served
populations.
1SnospreadoftheVirusiromthevaccineestocontacts.
IMMUNITY:Thevaccinehasconvincinglydemonstrated
toprovideimmunityto
evenseverelymalnourished4.Leveragethelife-courseapproachfordeliveryofne
children.Immunitydevelops11to12daysaftervaccination
andappearstobeoflongduration,probablyforlife.One
doseoftnevaccinegivenatll-12
monthsofageappearsto
give95percentprotectionandwithtwodoses98percent
protection.Infantsvaccinatedattheageof9monthsshow
sero-conversionofabout90percent(20).
secondroutinedoseofmeaslesandrubellacontaininng
vaccinesandforcatch-upvaccination:andntegrate
measlesandrubellaactivitieswithotherhealthandnon
healthactivities.
5.Ensureoutbreakpreparednessfortimelydetectionand
ffectiveresponsetolimitthespreadofmeaslesandd
rubellaandreducerelatedmorbidityandmartaliry.CONTACTS
months
maybeprotectedagainstmeasleswith
measlesvaccine,providedthatthisisgivenwithin3daysof
exposure.Thisisbecause,theincubationperiodofmeasles
Inducedbythevaccine
isabout7days,comparedwith
10daysforthenaturallyacquiredmeasles.
Susceptiblecontactsovertheageof
6.Ensurecontinued,timelyandqualitysupplyofmeasies
andrubellacontainingvaccines,vaccinationsupPpies
andlaboratoryreagentsandthatmeasiesandrubellaa
ctivities,includingsurveillance.aresustainably
financed.
ADVERSEEFFECTSOFVACCINE
Syndrome(TSS)occurswhenmeaslesvaccine
1s
Contaminatedorthesamevialisusedformorethanone
Toxicshock
7.Fosterresearchandinnovationtoovercomebarriersto
achievehighmeaslesandrubellapopulationimmunity
andtogenerateandusehighqualitydiseaseand
Eessiononthesamedayornextday.Thevaccineshouldnot
Deusedafter4hoursofopeningthevial.TSSistotally
preventableandreflectspoorqualityofimmunizanon
VICes.ThesymptomsofTSSaretypical.Severewatery
Larnoea,vomitingandhighfeverarereportedwithiniew
noursofmeaslesvaccination.Thereareusuallyaclusterolrecommended:(a)Isolationtordaysatteronsetofrash,
es
asallinfantsvaccinatedfromcontaminatedvialwillbe
ected.
Thismaycausedeathwithin48hours.Case
tatalityratesarehigh(20).
2.Immunoglobulin
programmedata.
Outbreakcontrolmeasures
Thefollowingcontrolmeasuresnavebeen
(b)immunizationofcontactswithin2daysotexposure
(ifvaccineiscontraindicated,immunogtabulinshouldbe
givenwithin3-4daysotexposure),and(c)prompt
immunizationatthebeginningofanepidemicisessentialta
limitthespread.
easlesmaybepreventedbyadministration
ot
ThOgobulin
(human)earlyintheincubationperiod.
aOse
recommendedbyWHOis0.25mlperkgofbody
EgntseeTable33onpage116).Itshouldbegivenwitnin
Eradicationofmeasles
Itisbelievedthatmeasles,likesnmallpox,isamenableto
eradication.Measlesimmunizationhasinitsfavourthefact

21. RUBELLA
10to14daysaftertherash.
(C)RASH:Therashisoftenfor
indicationofthediseaseinchildren.Itappearsfirst
afterthe16thweekofpregnancy,althoughsensorineura
nearingdeficitsmayoccurafterexposureuptoweekZ0OI
gestation.ThedefectsassociatedwithCRSinclude
ophthalmic(e.g.cataracts,microphthalmia,glaucoma,
thetace,usuaiywithin24hoursof#h
ars
irst
omalsymptoms.Ttisa
minute,discrete,pinkish,
PaCularrashandnotconnuentastherashofmeaslesanditpiqmentaryretinopathy,chorioretinitis),
audohepruritic.Conjunctivitismayoccur.Therashspreads
moluto
thetrunkandextremifies,bywhichtimeitisoften
no
longerapparent
Onneace.Iherashspreads
muchno
nd
clearsmorerapidlythantherashofmeasles.Itanearsaltogetherbythethirdday.Therashisan
nconstantfeatureoI
thedisease;itISabsentinsubclinicalnTheincidenceofrubellainfectionwithoutrashmay
he
upto25percent(4).(d)COMPLICATIONS: Inrare
instances
artnraiglamayoccurin
severaljointsinadults,
especiallyyoung
Women..Encephalitisisveryrare.
Thrombocytopenicpurpuranasalsobeenobservedasa
complication.Mentionhasbeenmadealreadyaboutthe
congenitalmaltormations.
sensorineuraldeafness),cardiac(e.g.peripheralpulmonar
arterystenosis,patentductusarteriosusorventricularseptal
detects)andcraniofacial(e.g.microcephaly)anomalies.CRS
canalsopresentwithothermanifestations,Suchas
meningoencephalitis,hepatosplenomegaly,
tnrombocytopenia,interstitialpneumonitisandradio-
lucencyinthelongbones(acharacteristicradiologica
patternofCRS).Infantswhosurvivetheneonatalperiod
maynaveseriousdevelopmentaldisabilities(suchasautism,
Visualandhearingimpairment),anddevelopmentaldelay.
ViralsheddingcancontinueinCRScasesbeyondIyearor
age,whichmayresultinvirustransmission(2).
hepatitis,
Prevention
Diagnosis
Becauseofitsmildnessandvariabilityofsymptoms,the
diseasecangounrecognizedunlessitisanepidemic.A
definitivediagnosisofrubella
ispossibleonlythroughvirus
isolationandserology.Throatswabsshouldbeculturedfor
virusisolation;ittakeslongerthanserologicaldiagnosis.The
haemagglutinationinhibition(HI)testisastandard
serologicaltestforrubella.However,
pretreatedtoremovenon-specificinhibitorsbeforetesting.
ELISAtestsarepreterredbecauseserumpretreatmentisnot
requiredandtheycanbeadaptedtodetectspecificIgM.
DetectionoflgGisevidenceofimmunitybecausethereis
onlyoneserotypeofrubellavirus.Toaccuratelyconfirma
recentrubellainfection,eitherariseinantibodytitermust
bedemonstratedbetweentwoserumsamplestakenatleast
10daysapartorrubella-specificlgMmustbedetectedina
singlespecimen.Itiscriticallyimportantinapregnant
Thecurrentlyusedrubellavaccinesarebasedonthelive
attenuatedRA27/3strain.Mostrubellavaccinesare
availableincombinationwithothervaccineantigenssuchas
measles,mumpsandvaricella(MR,MMR, MMRV,
respectively)andalsoinamonovalentformulation.Each
doseofanRCVcontainsaminimumnumberofinfectious
units(2l000plaque-formingunitsor50%cellculture
infectiousdose).Whenstoredat4°C,mostRCVshavea
shelf-lifeof2-3years.Monovalentrubella,MRand
MMR
vaccinesshouldbestoredat2-8°C,protectedfromlight.
Diluentvialsmaybestoredatambienttemperaturesbut
mustneverbefrozen.Thestandardvolumeofasingledose
ofRCVis0.5ml,andthevaccine
is
subcutaneously.Thepreferredsiteofinjectionisthe
anterolateralthighorouteraspectofupperarm,depending
ontheageoftheindividual(2).
erummustbe
suallyinjected
Becauserubellaisnotashighlyinfectiousasmeaslesand
becausetheeffectivenessof
1doseofanRCVis>95%,
evenat9monthsofage,only
1
doseofrubellavaccine
is
requiredtoachieverubellaeliminationifhighcoverageis
achieved.However,whencombinedwithmeasles
vaccination,itmaybeeasiertoimplementaseconddoseof
RCV'susingthesamecombinedMRvaccineorMMR
vaccineforbothdoses.RCV'scanbeadministered
concurrentlywithinactivatedvaccines.Asageneralrule,
livevaccinesshouldbegiveneithersimultaneouslywith
RCV's,oratleast4weeksapart.Anexceptiontothisisoral
poliovaccine,whichcanbegivenatanytimebetoreorafter
RCV'swithoutinterferingintheresponsetoeithervaccine.
InterferencemayoccurbetweenMMRandyellowfever
vaccinesiftheyaresimultaneouslyadministeredtochildren
<2yearsofage(8).
woman(6).
cONGENITALRUBELLASYNDROME (CRS)
Connitalrubellasyndrome(CRS)referstoinfantsbon
withdefectssecondarytointrauterineinfectionorwho
manifestsymptomsorsignsofintrauterineintection
sometimeafterbirth(5).Congenitalinfectionisconsidered
tohaveOccurred
iftheintfanthaslgMrubellaantibodies
Shortlyafterbirth(aslgMantibodiesdonotcrossthe
placenta,theirpresenceindicatethattheymusthavebeen
synthesizedbytheinfantinutero)oriflgGantibodiespersist
Ormorethan6months,bywhichtimematernallyderived
antibodieswouldhavedisappeared.ntrauterineintection
wIth.rubellaisassociatedwithchronicpersistenceofthe
VIrus,inthenewborn.Atbirth,virus
iseasilydetectablein
pharyngealsecretions,multipleorgans,cerebrospinalIuia,
rne,andrectalswabs.Viralexcretionmaylastfor12-18
monthsafterbirth,butthelevelofsheddinggradualy
decreaseswithage(6)
Rubellainfectioninhibitscelldivision,andthis
is
probablythereasonforcongenitalmalformationsandlow
Weight
(7).Theclassictriadofcongenitaldetectsare
ainess,cardiacmalformationsandcataracts.
ubella
infectionina
woman
whobecomesinfected(i.e.
cmptomatic
orsymptomaticdisease)justbefore
maln
anduptothefirst8-10weeksofgestation
causes
a
econgenitalabnormalitiesinupto90%ofintections,
may resultinmiscarriageorstillbirth.Congenital
ales
associatedwithmaternalrubellainfection
arerare
Thevaccineinducedimmunitypersistsforlifetime.In
ordertoprovidedirectprotectionagainstrubella,allnon-
pregnantwomenofreproductiveagewhoarenotalready
vaccinatedorwhoaresero-negativeforrubellareceiveone
doseofRCV(2).
Precautionsandcontraindications
RCVsshouldnotbegiventoanyonewhohas
experiencedasevereallergicreactionafteraprevious
vaccinedoseorvaccinecomponent.Itisrecommendednot
providethevaccinetothosewithactiveTBorsevere
immunodeficiency(includingindividualswithsymptomatic
HIVinfection,AlDS,Congenitalimmunedisorders,
malignanciesoraggressiveimmunosuppressivetherapy).

22. ageofincidenceofmumpsishigherthanwithmone
chickenpoxorwhoopingcough.However,noageis
oy
ifthereisnopreviousimmunity.hediseasetendst
moresevereinadultsthaninchildren.(b)IMMUNITY.
attack,clinicalorsubclinical,isassumedtoinducelifele
immunity.Thereisonlyoneantigenictypeofmumpsvir
anditdoesnotexhibitsigniticantantigenicvariation
(
Mostinfantsbelowtheageof6monthsareimmunebecau
ofmaternalantibodies.
168 EPIDEMIOLOGY OFCOMMUNICABLE DISEASES
Rubellavaccinationshouldbeavoidedinpregnancy
becauseofatheoretical(butneverdemonstrated)riskof
teratogenicoutcomes.Womenplanningapregnancyare
advisedtoavoidpregnancyfor
1monthafterrubella
vaccination.InadvertentvaccinationwithRCVduring
pregnancyisnotanindicationforterminatingthe
pregnancy.Peoplewhoreceivebloodproductswaitatleast
3monthsbeforevaccinationwithRCV,and,ifpossible,
avoidadministrationofbloodproductsfor2weeksafter
vaccination(2).
Environmentalfactors
Globalmeaslesandrubellastrategicframework
(2021-2030)
Mumpsislargelyanendemicdisease.Casesocc
throughouttheyear,butthepeakincidenceisinwinteran
spring.Epidemicsareoftenassociatedwithovercrowding,
Refertopage165forthedetails.
Modeoftransmission
References
Thediseaseisspreadmainlybydropletinfectionane
afterdirectcontactwithaninfectedperson
1.WHO(2016),RubellaFactsheet,March2016.
WHO(2020),WeeklyEpidemiologicalRecord,No.27,3rdJuly2020.
3.Fovbes,J.A.(1969).AmericanJ.Dis.Child.,118:54.Valman,H.B.(1981),Brit.Med.J.283:1038.
Walter,A.0.etal(1984).JAMA2511988.
6.Jewetz,MelnickandAdelberg'sMedicalMicrobiology,28thed.,2019.7.Dudgeon,J.A.(1969).Am.J.Dis.Child,118:35.
WHO(2020),SummaryofWHOPositionPapersRecommendedRoutineImmunization
forChildren.
Incubationperiood
Variesfrom2to4weeks,usually14-18days.
Clinicalfeatures
Mumpsisageneralizedvirusinfection.In30-40percentofcasesmumpsinfectionisclinicallynon-apparent.In
clinicallyapparentcases,itischaracterizedbypainandswellingineitheroneorboththeparotidglandsbutmayalsoinvolvethesublingualandsubmandibularglands.Oftenthechildcomplainsof"earache"ontheaffectedsidepriortotheonsetofswelling.Theremaybepainandstiffnesson
openingthemouthbeforetheswellingofthegland
isevident.Mumpsmayalsoaffectthetestes,pancreas,CNS,ovaries,prostate,etc.Inseverecases,theremaybefeverheadacheandotherconstitutionalsymptomswhichmay
last
from3-5days.Theswellingsubsidesslowlyover1-2weeksCOMPLICATIONS
Thoughfrequent,arenotseriousTheseincludeorchitis,
ovaritis,pancreatitis,
meningoencephalitis,
thyroiditis,
neuritis,hepatitisandmyocarditislesticularswellingandtenderness
denoteorchitis,
which
themostcommon
extrasalivary
glandmanitestationmumpsinadults.Itisunilateralinabout75percent
cases.
Highfeverusually
accompaniesorchitis,whie
developstypically
7-10daysaftertheonsetofparotitisabout25-40percentofpost-pubertal
men(4).Bilater
orchitisisrareandtheassumptionthatmumpsorchitisleadtosterilityisill-founded
(5).Upperabdominal
pal
nausea
andvomiting
suggest
pancreatitis.
Mumpsleadingcauseofpancreatitis
inchildren.Itoccurs
inab
4percentofpatients(6).Lowerabdominal
pain
Ovarian
enlargement
suggest
oophoritiswhichoccur
5percentofpostpubertal
women,
usually
unilatera
Whilesome
instances
ofdiabetes
haveoccurred
in
cn
following
mumps
infection,
acausalrelationship
has
bedemonstrated
(5).Rarer
complications
include
deafness,
cerebellar
ataxia,facial
palsyandtransverse
Encephalitis
isassociated
withcerebral
oedema
neurologic
manifestations
andsometimes
death
15%ofmumps
patientsmaydevelop
meningits
muchsmaller
proportion
(0.02-0.03%)
may
encephalitis.
Mumps
isoneofthemaininfectious
sensorineural
deafness,
whichaffects
approxima
100,000
mumps
cases
(6)
MUMPS
AnacuteinfectiousdiseasecausedbyanRNAvirusclassified
asgenusRubulavirus
ofthefamilyparamyxoviridae
whichhasapredilectionforglandularandnervoustissues.Clinically,thediseaseisrecognizedbynon-suppurativeenlargementandtendernessofoneorboththeparotidglands.Otherorgansmayalsobeinvolved.Constitutionalsymptomsvary,ormaybeinapparent.Thediseaseoccursthroughouttheworld.Althoughmorbidityratetendstobehigh,mortalityrateisnegligible.
Inmostpartsoftheworld,theannualincidence
ofmumpsintheabsenceofimmunizationisintherangeof100-1000cases/100,000
populationwithepidemic
peakevery2-5years.Naturalinfectionwiththisvirusisthoughttoconferlifelongprotection(1).
Agentfactors
(a)AGENT
Thecausativeagent,Myxovirus
parotiditis
is
aRNAvirusofthemyxovirusfamily.Theviruscanbegrownreadilyinchickembryoortissueculture.Thereisonlyoneserotype.(b)SOURCEOFINFECTION:
Bothclinical
andsubclinicalcases.Subclinicalcaseswhichaccountfor30-40percentofallcases(2)appeartoberesponsible
formaintainingthecycleofinfection.TheviruscanbeisolatedfromthesalivaorfromswabstakenfromthesurfaceofStenson'sduct.Virushasalsobeenfoundintheblood,urine,humanmilkandonoccasionintheCSE(c)PERIODOFCOMMUNICABILITY
:
Usually4-6daysbeforetheonsetofsymptomsandaweekormorethereafter.
Theperiodofmaximuminfectivityisjustbeforeandattheonsetofparotitis.Oncetheswellingoftheglandshassubsided,thecasemayberegardedasnolongerinfectious.(d)SECONATTACK
RATE :
Estimatedtobeabout86percent.
polyarthritis,
hydrocephalus,
encep
Hostfactors
(a)AGEANDSEX :Mumpsisthemostfrequentcauseofparotitisinchildrenintheagegroup5-9years.Theaverage
Mumps
infection
inthefirsttrimester
ofpr
associated
witha25%
incidence
ofspontaneous

23. BIRDFLU
171
Revesyndrome(fattyliverwithencephalopathy)
isarare
ndSeverecomplicationofinfluenza,usuallyAandBtype,
particularlyinyoungchildrenbetween2and16yearsofage,
Itconsistsofrapidlyprogressivehepaticfailureand
ncephalopathy,andthereisabout10-40percentmortality
rate,
Thepathogenesisisunknown,butthesyndromeis
associatedwithaspirinuseinavarietyofviralinfections(7).
PANDEMICINFLUENZA
A(H,N,)2009
(SWINEFLU)
ThepandemicinfluenzaA(H,N,)2009virusdiffersinits
pathogenicityfromseasonalinfluenzaintwokeyaspects.
First,asthemajorityofhumanpopulationhaslittleorno
pre-existingimmunitytothevirus,theimpactofthe
infectionhasbeeninawideragerange,inparticularamong
childrenandyoungadults.Secondly,theviruscaninfectthe
lowerrespiratorytractandcancauserapidlyprogressive
pneumonia,especiallyinchildrenandyoungtomiddle-aged
adults.
AVIANINFLUENZA(8)
(BIRDFLU)
Avianinfluenzareierstoalargegroupofdifferent
influenzavirusesthatprimarilyaffectbirds.Onrare
occasions,thesebirdvirusescaninfectotherspecies,
includingpigsandhumans.Thevastmajorityofavian
influenzaviruses
do
notintecthumans.However,avian
HN,isastrainwithpandemicpotential,sinceitmight
ultimatelyadaptintoastrainthatiscontagiousamong
humans.Oncethisadaptationoccurs,itwillnolongerbea
birdvirus
-itwillbeahumaninfluenzavirus.Influenza
pandemicsarecausedbynewinfluenzavirusesthathave
adaptedtohumans.Healthexpertshavebeenmonitoringa
newandextremelysevereinfluenzavirustheHN,
strain
foralmost15years.Fortunately,thevirusdoesnotjump
easilyfrombirdstohumansorspreadreadilyand
sustainablyamonghumans.Onceafullycontagiousvirus
emerges,itsglobalspreadisconsideredinevitable.
FollowingitsemergenceinMarch2009,pandemic
A(H,N)2009virusspreadrapidlythroughouttheworld,
leadingtothedeclarationofaninlfuenzapandemicby
WHOon11thJune2009(9).Theworldisnowin
post-pandemicperiod.InIndiaitcauseslocaloutbreaks.
During2018,Indiareported14,971casesand1,103deaths,
acasefatalityrateof7.36percent(10).
Basedonknowledgeaboutpastpandemics,the(H,N,)
2009virusisexpectedtocontinuetocirculateasaseasonal
virusforsomeyearstocome.Whilelevelofconcernisnow
greatlydiminished,vigilanceonthepartofnationalhealth
authoritiesremainsimportant,whenthebehaviourofH,N
virusasaseasonalviruscannotbereliablypredicted(11).
On26thSeptember2011WHOhasadaptedanewnomen-
clatureasInfluenzaA(H,N,)pdm09(12).Transmission
Humaninfectionswithavianinfluenzaviruses,though
rare,havebeenreportedsporadically.Humaninfectionsare
primarilyacquiredthroughdirectcontactwithinfectedlive
ordeadpoultrybirdsorcontaminatedenvironments,such
aslivebirdmarkets.
Incubationperiod
Theincubationperiodappearstobeapproximately1-4
days,butcouldrangeupto7days.
Casedefinitions(13)
Incubationperiod
Suspectedcase:AsuspectedcaseofinfluenzaA(H,N,)
2009isdefinedasapersonwithacutefebrilerespiratory
illness(fever238°C)withonset(a)within7daysofclose
contactwithapersonwhoisaconfirmedcaseofinfluenza
A(H,N,)2009virusinfection,or;(b}within7daysoftravel
toareaswherethereareoneormoreconfirmedcases,or
(c)residesinacommunitywherethereareoneormore
confirmedinfluenzaA(H,N,)2009cases.
2-5days.
Diagnosis
DiagnosisisconfirmedbyRT-PCR.Rapidinfluenza
diagnostictests(RDTs)areavailable,buttheyhavelower
sensitivitycomparedtoRT-PCR.
Treatment
ProbablecaseAprobablecaseofinfluenzaA(H,N,)
Someantiviraldrugs,notablyoseltamivirandzanamivir
canreducethedurationofviralreplicationandimprove
prospectsofsurvival.
Prevention
Publichealthmanagementincludespersonalprotective
measureslikeregularhandwashingandproperdrying;good
respiratory
coughingorsneezing);earlyself-isolation;avoidclose
contactwithsíckpeople;andavoidtouchingeyes,mouth
andnose
2009virusinfectionisdefinedasapersonwithanacute
febrilerespiratoryillnesswho:(1)ispositiveforinfluenzaA,
butunsubtypableforH,andH,byinfluenzaRT-PCRor
reagentsusedtodetectseasonalinfluenzavirusinfection,or;
(2)
ispositiveforinfluenzaAbyaninfluenzarapidtestoran
infiuenzaimmunofluoresenceassay(1FA)andmeetscriteria
forasuspectedcase,or;(3)individualwithaclinically
compatibleillnesswhodiedofanunexplainedacute
respiratoryillnesswhoisconsideredtobeepidemiollogically
linkedtoaprobableorconfirmedcase.
ygiene(coveringmouthandnosewhen
Confirmedcase:Aconfirmedcaseofpandemicinfluenza
A(H,N,)2009virusinfectionisdefinedasapersonwithan
acutefebrilerespiratoryillnesswithlaboratoryconfirmed
influenzaA(HN)2009virusinfectionatWHOapproved
laboratorybyoneormoreofthefollowingtests:
Vaccine
ntheyear2007,avaccineforbirdfluwaslicensed,this
accineisforpeople18
yearsthrough64yearsofage.Itis
aninactivatedinfluenzavaccinegivenintwodoses,28days
art.Therecipient
can
havepainandtendernessatthe
ection
site,headache,musclepainandgeneral
illfeeling.
Sa
omeothervaccineswereapproved,butatthetimeof
pandemic,(astheHN,continuallymutates),thecurrent
pleofHN,
cannotbedependedupontowork.
a.RealTimePCR
b.Viralculture
C.Four-foldriseininfluenzaA(H,N,)virusspecific
neutralizingantibodies.

24. 172 PDEMIOLOGY OFcOMMUNICABLE DISEASES
Clinicalfeatures(14)
Awideclinicalspectrumofdiseaserangingfromnon
ebrilemildupperrespiratoryillness,febrileinfluenzaiike
itness(ILI),tosevereorevenfatalcomplicationsincu
apidyprogressivepneumoniahasbeendescribed.
he
casefatalityrateissmilartoseasonalinfluenzai.e.about0.5
Percent:howeverthiscouldchange(15).Theclinical
featuresareasdescribedbelow:
Signsandsymptomsotprogressive
sease
Patientswhopresentinitially
with
influenzamayprogresstomoreseverediseaseD
plicatea
canberapid(i.e.withinz4hours).Thefollowingression
uncomp
oftheindicatorsotprogression,whichwould
necessitate
Some
anurgentreviewolpatientmanagement.
(a)SymptomsandsignsSuggestingoxygen
impa
cardiopulmonaryinsutticiency:
Shortness
ofbreath(withactivityoratrest),diffes
inbreathing,turningbIue,bloodyorcoloured
chestpain,andlowbloodpressure;
Inchildren,fastorlabouredbreathing:and
Hypoxia,asindicatedbypulseoximetry
(b)SymptomsandsignssuggestingCNScomplications
-Alteredmentalstatus,unconsciousness,drowsines
or
(a)Uncomnplicatedinfluenza
o
(1)LIsymptomsincludefever,cough,sorethroat,
rhinorrhoea,headache,musclepain,andmalaise,
butnoshortnessofbreathandnodyspnoea.Patienis
maypresentwithsomeorallotthesesymptoms.
(2)Gastrointestinalillnessmayalsobepresent,suchas
diarrhoeaand/orvomiting,especiallyinchildren,
butwithoutevidenceofdehydration.
sputum,
difficulttoawakenandrecuringor
persisten!
convulsions(seizures),conrusi10n,severeweakness,
or(b)Complicatedorsevereinfluenza
(1)Presentingclinical(e.g.shortnessofbreath
ayspnoea,tachypnea,hypoxia)and/orradiological
Signsoflowerrespiratorytractdiseasee.g.
pneumonia),centralnervoussystem(CNS)
involvement(e.g.encephalopathy,encephalitis),
severedehydration,orpresenting
seconaary(d)Severedehydration,manitestedasdecreasedactivity
complications,suchasrenalfailure,multiorgan
tailure,andsepticshock.Othercomplicationscan
includerhabdomyolysisandmyocarditis.
(2)Exacerbation
ofunderlyingchronicdisease,
includingasthma,COPD,chronichepaticorrenal
failure,diabetes,orothercardiovascularconditions.
(3)Anyotherconditionorclinicalpresentationrequiringcomplicationsfromseasonalinfluenza.Theseinclutethe
paralysis.
(c)Evidenceofsustainedvirusreplicationorinvasive
secondarybacterialintectionbasedonlaboratory
testino
or
clinicalsigns(e.g.persistenthighfeverand
other
symptomsbeyond3days).
diziness,decreasedurineoutput,andlethargy.
Riskfactorsforseveredisease(14)
Riskfactorsforseverediseasetrompandemic
influenza
A(H,N,)2009virusintectionreported
todateare
consideredsimilartothoseriskfactorsidentified
for
hospitaladmissionforclinicalmanagement.
(4)Anyofthesignsofprogressivedisease.
followinggroups
(1)Infantsandyoungchildren,inparticular<2years
AsCOVID-19andinfluenza,botharerespraro
(2)Pregnantwomen
illnesses,theysharemanysimilarities.
Itisveryimportantto
differentiatethesebothdiseasessoastotaketimely
appropriateaction
tomanagethedisease.The
differentiatingpointsareasfollows(16)
(3)Personsofanyagewithchronicpulmonary
disease(eg
asthma,COPD)
(4)Personsofanyagewithchroniccardiacdiseasees
congestivecardiactailure)
COVID-19
INFLUENZA
(5)Personswithmetabolicdisorders(e.g.diabetes
Incubationperiod2-14days 1-4days
Fever
-Chills
Cough
-Fatigue
-Bodyaches
andpains
-Headache
-Runnyorstuttynose
-Sorethroat
(6)Personswithchronicrenaldisease,
chronicnepu
disease,certain
neurological
conditionsincu
Eromuscular,
neurocognitive,and
seizuredisorue
ndemoglobinopathies,or
immunosuppression,
w
duetoprimary
immunosuppressive
con
h
a6
HIVintection,orsecondary
condition3,
mmunosuppressive
medicationor
malignancy
(7)Childrenreceivingchronicaspirin
therapy
(8)Personsaged65yearsandolder.
A
higherriskofsevere
complications
om
als0bee
intluenza
A(H,N,)2009virusinfectionuin
thos
eportedinindividualswhoareobese
particularny
whoaremorbidlyobese.
Fever
Cough
-Fatigue
Common
symptoms
-Shortnessof
breath
-Lossofsmell
-Lossoftaste
pandemic
-Bodyaches
andpains
-Headache
-Runnyor
stuffynose
Less
common
symptoms
-Nauseaor
diarrhoea
Laboratorydiagnosisof
ndemic
influenzaA(Laboratorydiagnosis
(14)
-Sorethroat
-Nausea
or
diarrhoea
Outbreakorforunusualcases,has
importantroCedu
ations
for
2009virus,especiallyatthebeginningtimplicatio
com
nmuniy
-
Gradual Rapid
Symptom
onset casemanagment,suchasintection
control
-Vaccinesare
available
Seasonalandswine
fluvaccineand
Considerationofantiviral
treatmentop thediag
anans
Vaccineand
medications
tneinappropriateuseofantibiotics.urtories
in
antiviralmedication
available.
laboratd
eacos
estscanbedonebyspecialized
chain
countries.Reversetranscriptase
olymerase

25. RiFLUEN7A 173
IRT-PCR)wilprovide
detectionO
ne
niection.
willprovidethemosttimelyandsensitive
no
mayshedvirusforalongertimeperiodandareaisoat
mcreasedriskfordevelopmentofantiviralresistant
virus.
Clinical
Specimenstobe
colecledforlaboratory
Infiuenzavaccine
arerespiratorymples.SamplesIromtheupper
tract,including
ambinationot
nasalor urrently,therearethreedifferent
influenzatechnologies
se,
toproduceinfluenzavaccines.
Theseinclude
gg-based,cell-cultured,andrecombinanttechnol0gies.
99-ased
inactivatedinfluenzavaccines
(IfVs)areprepared
TOminactivatedand
detergent-solubilizedvirionparticies
containingHAandNAproteins
preparedinembryonated
Chickeneggs.Theliveattenuatedvaccine
(LATV)
1sprepared
O atenuated,lessvirulentvirusstrains.Cell-cuitured
espia
cpirato
alsamples,anda
hroatswabareadvised.nasoplharyngeal
samples,
Recent
evidencesupposviralreplicatioiandrecoveryot
(H,N,)2009virusirom
lowerrespiratorytract
nandemnchealandbronchialaspirates)inpalients
amp
lowerrespiratoryiractsymplomsandinthese
presel
ch
sampleshavehigherdiagnosticyieldsthan
fromtheupperrespiratorytract.
samples
When
influenzavirusesareknowntobecir
TCulatinginavaccinesareproducedbygrowingtheintluenzavirus
in
patientspresentingWithfeaturesof
animalcells,allowingforafastermanutacturing
process.
Ihoughhen'seggsarenotused.traceamounis
oegg
PTOen
maybetundinthesevaccines.Therecombinant
nu
VaccineisanalternativemethodthatisolatestheHAgeneand
proteinsinordertoobtainanimmunogenicresponsewtigut
Tneuseofchickeneggs.Thisvaccineisproducedininsectcen
CuuresàndcontainsthreetimestheamountotHAcompared
witnthestandard-dosepreparation.
Itiscurrentlytheoniy
availableinfluenzavaccinethatiscompletelyegg-tree(
7).
wotypesofinfluenzavirusesareincludedinthe
intluenzavaccine:humaninfluenzaAvirusandintluenzab
irus.vaccinecompositionisreviewed
annuallyand
updatedasneededbasedonthecirculatingViruses.extent
towhichthosevirusesarespreading.andhow
gooathe
responsewastothepreviousyearsvaccine.TheWorld
HealthOrganizationmakesrecommendationsabouttne
specificvirusestobeincluded.
munity,
omplicatedintluenzacanbediagnosedonclinicaland
Unmiologicalgrounds.Allpatienisshouldbeinstructedto
forfollow-up,should
theydevelopanysignsor
return
i
sympto
ofprogressivediseaseorfailtoimprovewithin
72hoursoftheonsetoisymptoms.
Diagnostictesting.wnenavailable,shouldbeprioritized
r
Datientsinwhomcontirmationotinfluenzavirusinfection
mayaffectcinicamanagement,includingpatients
consideredat-riskana/ortnosewitncomplicated,severe,or
progressiverespiratory1lness.Inaddition,resultsof
diagnostictestingmayalsobevaluableinguidinginfection
controlpracticesandmanagemento
apatient'sclose
contacts.Under
nocircumstancesshouldinfluenzadiagnostic
testing
delayinitiationofinfectioncontrolpracticesor
antiviraltreatment,iTpandemicintluenza
A(H,N,)2009
disease
issuspectedclinicallyandepidemiologically(14).
Severalrapidinfluenzadiagnostictestsincluding(so
calledpoint-of-carediagnostictests)arecommercially
available.However,studiesindicatethatrapiddiagnostic
testsmissmanyintectionswithpandemic(H,N,)2009virus
and,therefore,negativeresultscannotruleoutdisease,and
shouldnotbeusedasgroundstowithholdtherapyorlift
Inactivatedinfluenzavaccine(iIVs)
IVsareavailablesince1940.Trivalent
IIVscontainthree
inactivatedviruses:typeA(H,N,).typeA(H,N,).and
typeB.Quadrivalentintluenzavaccineswereiniroducedin
theyear2013-2014season.Theycontainthesameantigens
astrivalentvaccines,withaddition
otanotherBstrainVirus.
increasingthelikelihoodforadequateprotection.IIVis
administeredbyintramuscularorintradermalroute.The
vaccineisavailableinbothpaediatric(0.25ml)andadult
(0.5ml)doseformulation.OnedoseofIVmay
be
administeredannuallyforpersons9yearsofageandolder.
Children6monthsthrough
Syearsot
agereceiving
influenzavaccineforthefirsttimeshouldreceivetwodoses
administeredatleast28daysapart.Annualimmunizationis
recommended(18).
infectioncontrolmeasures.
Intectioncontrol
Evidencetodatesuggeststhatpandemic(H,N,)2009
virusistransmittedsimilarlyasseasonalinfluenzaAandB
viruses.Appropriateinfectioncontrolmeasures(standard
plusdropletprecautions)shouldbeadheredtoatalltimes,
whichincludesstrictadherencetohandhygienewithsoap
andwateroranalcoholbasedhandsanitizer,andtocover
mouthandnosewithtissueorhandkerchiefwhencoughing
Or
sneezing.
lfillpersonsmustgointothecommunitye.g.to
seekmedicalcare,theyshouldwearafacemaskforeduce
tneTiskofspreadingthevirusinthecommunity.
Thevaccineisabout60percentetfectiveamonghealthy
personsyoungerthan65yearsotage.Onvaccination,the
vaccinebecomeseffectiveafter14days.Thoseinfected
shortlybefore(1-3days)orshortlyatterimmunizationcan
stillgetthedisease(18).Vaccinatedindividualscanalsoget
infectedwithotherstrainofinfluenzavirusforwhichthe
Whenever
performinghigh-riskaerosol-generating
procedures(forexample,bronchoscopyoranyprocedure
Vingaspirationoftherespiratorytract)useaparticulate
espirator(N95,FFP2orequivalent),eyeprotection,
gown,
andgloves,andcarryouttheprocedureinanadequately
ventuatedroom,eithernaturallyormechanicaly.
nedurationofisolationprecautionsforhospitalized
atientswithinfluenzasymptomsshouldbecontinueato
daysafteronsetofillnessor24hoursaftertheresolutior
ver
andrespiratorysymptoms,whichever
1s
longer,
eapatientisinahealth-carefacility.Forprolongea
linesswithcomplications
1.ePofacute
illnessasures
shouldbeusedduringthedurationofacuteilness
untilthepatienthasimproved
dnatientsstandardinfluenzavaccines,providingabetterimmune
vaccinedosenotprovideprotection(18).Theimmunity
lastsfronm6-12months.Thevaccineis50-60percent
efectiveinpreventinghospitalizationand80percent
effectiveinpreventingdeathamongelderlypersons(18).
Thevaccineshouldbestoredattemperatureof2-8°C.It
shouldnotbefrozen.
Forthosepersonsaged65yearsandolder,thereare
currentlytwoinfluenzavacCinesdesignedtoovercomethe
waningimmuneresponsetound
inthispatientpopulation
high-doselIV(HD-IV)andadjuvantedIIV(allV).Both
formulationsareavailableonlyasatrivalentvaccine.The
HD-IIVcontainstourtimestheHA-antigencomparedwith
onisneededincaringforimmunosuppressedpatientsstandard
innuenzavaccines,providingabetterimmune

26. 174 EPIDEMIOLOGYOFCOMMUNICABILE DISEASES
asthma,arecentwheezingepisode,reactivearesponseandreducingclinicaloutcomesassociatedwith
intluenzainfectioninthispatientpopulation.When
comparedwithpatientswhoreceivedstandard-dosetrivalent
intuenzavaccines,HD-IIVwasshowntobe24%more
eftectiveinpreventinglaboratoryconfirmedinfluenza(17).
rwa
orotherchronicpuimonaryorcardiovascular
conditions
ase
metabolicdiseasesuchasdiabetes,renal
hemoglobinopathy,suchassicklecelldisease:
oradolescentsreceivinglong-termtherapywithasnen
aspirin-containingtherapy,becauseoftheassociator
Reyesyndromewithwild-typeintluenzainfection of
disease,
Orandc
SIDEEFFECTS
inthesegroupsshouldreceiveinactivatedinfluenza.eTSons
vaccine.
Aswithotherlive-virusvaccines,LAIVshould
not
Inactivatedvaccines,administeredbyinjection,
commonlycauselocalreactionssuchassoreness,swelling
andrednessattheinjectionsite,andlessoftencancause
tever,muscleorjoint-achesorheadache.Thesesymptomsdisease,includingHIV,orwhoarereceivingimm
aregenerallymildanddonotneedmedicalattention,and
lastfor1-2days.Fever.achesandheadachescanoccur
morefrequentlyinchildrencomparedtoelderlypeople.
Rarely,theseinlfuenzavaccinescancauseallergicreactionscontainsresidualeggprotein,itshouldnotbeadministeod
suchashives,rapidswellingofdeeperskinlayersand
tissues,asthmaoraseveremultisystemallergicreactiondue
to.hypersensitivitytocertaincomponents.
giventopersonswhoareimmuno-suppressedbecanc
suppressivetherapy.Pregnantwomenshouldnoto
rec
LAIV.Immuno-suppressedpersonsandpregnantwOm
shouldreceiveinactivatedintluenzavacine.Since1A
topersonswithahistoryosevereallergytoeggor
an
othervaccinecomponent.AhistoryofGuillain-Baro
syndrome(GBS)within6weeks1ollowingaprevious
doso
ofinfluenzavaccine
isaprecautionforLAIV
CONTRAINDICATIONS
Sincethespreadoftheepidemicsofinfluenza
unstoppableandthereislimitationofvaccine
availability,
WHOrecommendsthatallthecountriesshouldimmuniza
theirhealthcareworkersasthefirstprioritytoprotectthe
essentialhealthintrastructure,andtopreventinitiationof
nosocomialspreadofdiseasetovulnerablepatients.WHO
recommendsthefollowinggroupsofpersonsbevaccinated
accordingtotheirorderofpriority:la)pregnant
women;
(b)individualsagedmorethan6monthswithoneofthe
severalchronicmedicalconditions;(c)healthyyoungadults
betweenage15-49years,(d)healthychildren;(e)healthy
adultsbetweenage49-65years;and
(1)healthyadultsaged
morethan65years.
Virusis
Asageneralrule,inactivatedvaccinesshouldnotbe
administeredto(19):
(1)Peoplewhohaveasevereallergytochickeneggs;
(2)Peoplewithahistoryofanaphylacticreactions
orother
life-threateningallergicreactionstoanyofthe
constituentsortraceresidueofthevaccine;
(3)Peoplewithhistoryofaseverereactiontoinfluenza
vaccination;
(4)PeoplewhodevelopedGuil
within6weeksofgettinganinfluenzavaccine;
(5)Childrenlessthan6monthsofage(inactivatedinfluenza
vaccineisnotapprovedforthisagegroup);and
in-Barresyndrome(GBS)
Treatment
(6)Peoplewhohaveamoderate-to-severeillnesswitha
fever(theyshouldwaittilltheyrecovertogetvaccinated).
Keyprinciplesforclinicalmanagementinclude
basic
symptomaticcare,earlyuseofantiviraldrugs
ifavailable,
forhighriskpopulations,antimicrobialsforco-intections,
andproactiveobservationforprogressionofilnes.
Liveattenuatedinfluenzavaccine
Liveattenuatedinfluenzavaccine(LAlV)wasapproved
forusein2003.
Itcontainsthesameinfluenzavirusesas
IIlV.
Thevirusesarecold-adapted,andreplicateeffectivelyinthe
mucosaofthenasopharynx.Ihevaccine
virusesaregrown
inchickeneggs,andthefinalproductcontainsresiduale99
protein.Thevaccineisprovided
inasingle-dosesprayer
unit;halfofthedose
issprayedintoeachnostril.LAIVdose
notcontainthimerosaloranyotherpreservative.LAIVis
approvedforuseonlyinhealthy,non-pregnantpersons
2to49yearsofage.Vaccinatedchildrencanshedvaccine
virusinnasopharyngealsecretionsforupto3weeks.
Hospitalcarerequiresearlysupplementaloxygentherapy
Tocorrecthypoxaemia,withsaturationmonitoring
attriage
andduringhospitalization,
ifposible,
caretul
una
replacement,antimicrobials,andothersupportive
care.iti
importanttoprovideappropriateantimicrobialstorotne
infectionswhichalsopresentwithsevererespiratoryai5a
Anumberofseverely
illpatientswithpandemic(HN
diseasedeveloprespiratorydistressrequiringmecnal
ventilationandintensivecaresupport.
Antiviraltherapy(14)
LAIVis87percenteffectiveagainstcultureconfirmed
influenzainchildren60-84monthsold;resultsin27per
centreductioninfebrileotitismedia;28percentreduction
inotitismediawithaccompanyingantibioticuse.
ntly
PandemicinfluenzaA(H,N,))2009virus
is
cuAl
usceptibletotheneuraminidaseinhibitoStors
OSeltamiVirandzanamivir,butresistanttothe
MZIn
amantadineorrimantadine.
SIDEEFFECTS
Thefollowing
ecommendations.
asummaryof
treatne
Liveattenuatedvaccinesàregivenviaanasalspray,and
cancommonlycauserunnynose,nasalcongestion,cough
andcanlessfrequentlycausesorethroat,lowgradefever,
irritabilityandmuscle-achesandheadache.Wheezingand
vomitingepisodeshavebeendescribedinchildrenreceiving
liveinfluenzavaccines(19).
(1)Patientswhohavesevereorprogressive
clinical
illness
Shouldbetreatedwithoseltamivir.Treatment
initiatedassoonaspossible.
(a)Thisrecommendationappliestoallpainachildren
groups,
includingpregnantwomen,andyou
2years,includingneonates.
CONTRAINDICATIONS
PersonswhoshouldnotreceiveLAlvincludechildren
youngerthan2yearsof
age;persons50yearsofageand
older;personswithchronicmedicalconditions,including
(b)Inpatientswithsevereorprogressivc
illness
highe
ne
respondingtonormaltreatmentregation
dosesofoseltamivirandlongerdu

27. MENINGOcocCALMENINGITIS 181
CONTRAINDICATIONS
Thecontraindications
toper100,000populationandmajoritycasesarecaused
by
erogroupBstrains.InAmericas,theincidenceofdiseaseis
ne
rangeof0.3to4casesper100,000population.
In
UnitedStates,themajoritycasesarecausedbyserTOgTOU
D,and
Y.InAsiamostmeningococcaldiseaseiscausedby
neningococcibelongingtoserogroupAorC(1)
MeingococcaldisesaseisendemicinIndia.Casesof
neningocOccalmeningitisarereportedsporadically
orn
a clusters.During2018,about3,382casesof
meningococcalmeningitiswerereportedinlndiawithabout
152deaths.Majorityofthecaseswerereportedtromoniy
fewstatesasshowninTablel.
ertussis
Vaccination
ertulopathy,apersonalorstrongfamilyhistoryof
are
anaphylactic
reaction,
ncep
onvulsionsorsimilarCNSdisorders:anyfebrile
euntilfullyrecovered:orareaction
reviouslygiveniiplevaccineinjections/101One
ofthe
,
PASSIVEIMMUNIZATION
merit
ofhyperimmune
globulininpertussis
rophylaxishasyetto.Deestablished.Sofar,thereis
n
no
ovidenceofitseiticacyinwell-controlledtrials(9).
The
controlofpertussisbyimmunization
isstilan
edproblem.Evenifthelevelofimmunization
reaches
100percent,ltsPpossioetnattnediseasewouldnotbe
oheliminatedbecausewhoopingcoughvaccineshave
eenclaimedtobemorethan90percenteffective.
TABLE
1
Keportedcasesanddeathsduet
nenngOcoCcalmeningitisinsomestatesinIndia201neve
State Case Deaths
References
Morley,David(1973).PaediatricPrioritiesintheDevelopingWorld,
AndhraPradesh 758 45
0MadhyaPradesh
UttarPradesh
Butterworths. 44
2.
WHO(2018),FactSheetPertussis.
3
WHO(1996),TheWoridiealthKeport1996,Fightingdisease
Fosteringdevelopment.
WHO(2010),WeeklyEpidemiologicalRecord,No.40,1stOct,2010.
5.Govt.ofIndia(2019),NationalHealthProfile2019,DGHS,Ministry
ofHealthandfamilyWelfare,NewDelhi.
6.Christie,A.B.(1980).InjectiousDiseases:EpidemiologyandClinical
Practice,3rded.,ChurchillLivingstone.
283
Rajasthan
WestBengal
44
967 80
Uttarakhand 12
Karnataka 153
Maharashtra
Bihar 499
Delhi 46
7.WHO(2005),WeeklyEpidemiologicalRecord,No.4,Jan.28,2005.
8.Jawetz,etal,MedicalMicrobiology,24thed.2007,ALangeMedical
Jharkhand
Andman&Nicobar
Odisha
Haryana
BooR. ZI
9.Manclark,C.R.(1981).BulWHO,59:9-15.
10.Gray,JamesA(198l).MedicineInternational,3,112.
33
335
Chhattisgarh 25
MENINGOCOCCAL MENINGITIS5
India 3,382 152
Source:(2)Meningococcalmeningitisorcerebrospinalfeverisan
acutecommunicablediseasecausedbyN.meningitidis.It
usuallybeginswithintenseheadache,vomitingand
stit
neckandprogressestocomawithinafewhours.The
meningitisispartofasepticaemicprocess.Thefatalityof
typicaluntreatedcasesisabout50percent.Withearly
Epidemiologicalfeatures
(a)AGENT:Thecausativeagent,N.meningitidisisa
gram-negativediplococci.12serotypeshave been
dragnosisandtreatment,casefatalityrateshavedeclinedto
lessthan8-15percent.
identilied,viz.GroupsA,B,C,29E,H,I,K,L,W135,X,Y,
Zbasedonthestructureofthepolysaccharidecapsule.The
majorityofinvasivemeningococcalintectionsarecausedby
organismsofserogroupsA,B,C,X,W135and
Y.Meningococcioftheseserogroupshavethepotentialto
causebothendemicdiseaseandoutbreakS.InAfrican
meningitisbelt,subgroupAhasbeenthemostimportant
causeofdisease(1).N.meningitidisisadelicateorganism;
itdiesrapidlyonexposuretoheatandcold.(b)SOURCE
OFINFECTION:Theorganismistoundinthenasopharynx
ofcasesandcarriers.Clinicalcasespresentonlyanegligible
sourceofintection.Moreoftentheintectioncausesmild
orevenunnoticeablesymptomsofnaso-pharyngitis.
4to35percentofthenormalpopulationmayharbourthe
organisminthenasopharynxduringinter-epidemicperiods.
Carriersarethemostimportantsourceofinfection.The
meandurationoftemporarycarriersisabout10months(3).
Duringepidemics,thecarrierratemaygoupto70-80per
cent.(c)PERIODOFCOMMUNICABILITY
meningococciarenolongerpresentindischargesfromnose
andthroat.Casesrapidlylosetheirintectiousnesswithin
24hoursofspecifictreatment.(d)AGEANDSEX:Thisis
predominantlyadiseaseofchildrenandyoungadultsof
bothsexeswithhighestaftackrateinintantsaged
3-12months.(e)IMMUNITY:Alagesaresusceptible.
Youngeragegroupsaremoresusceptiblethanoldergroups
Problemstatement
Distributionworldwide,occurringsporadicallyandin
smalloutbreaksinmostpartsoftheworld.InsomeregionsS
thisendemicsituationmayalternatewithdevastating,
unpredictableepidemics.ThisisthecaseintheAfrican
meningitisbelt,whichistheregioninSub-SaharanAfrica
StretchingfromSenegalinthewesttoEthiopiaintheeast.
nis
regionisinhabitedbyaround400millionpeople.Inthe
Africanmeningitisbelt
meningococcalepidemicis>100casesper100,00
pOpulationperyear.Intheendemiccountries,theincidence
O cases,2-10casesand<2casesper100,000
pulationperyearcharacterizehigh,moderateandlow
emicityrespectivety.Anoutbreakoutsidethemeningitis
Oetmay
bedefinedasasubstantialincreaseninvasiv
gocoCcaldiseaseinadefinedpopulationabovethat
wnichisexpectedbyplaceandtime
().-
theWHOdefinitionofa
Until
uringrecentyears,severalseriousoutbreaksaffecting
rouscountrieshaveoccurredintropicalandtemperate
Fs
ofothercontinents,viz,Americas,AsiaandEurope.In
etneincidenceofdiseaserangesfrom0.2to14cases

28. COVID-19191
Epidemiologicalaspect
Halthcareworkers,especiallythoseinvolvedin
cocuresgeneratingaerosols,accountedfor21percentof
2.Effectiveisolation
ofSARSpatients
inhospitals;
3,Appropriateprotectionofmedicalstafftreatingthese
patients;
4.Comprehensiveidentificationandisolationofsuspected
SARScases
all
cases.
Maximumvirusexcretionfromtherespiratorytract
imple
hygienic
measuressuchas
hand-washingafter
TOuchingpatients,useofappropriateand
well-fitted
masks,andintroductionofinfectioncontrol
measures;
6.Exitscreeningofinternationaltravellers;
7.Timelyandaccurate
reporting
intormationwithotherauthoritiesand/or
governments.
occursonaboutday10ofillnessandthendeclines.The
fciencyoftransmissionappearstobegreatestfollowing
toseverely
illpatientsorthoseexperiencingrapidexposure
linicaldeterioration,usualyduringthesecondweekof
lness.Whensymptomaticcaseswereisolatedwithin5days
af
the
onsetofillness,1ewcasesofsecondarytransmission
rCurred.Therewasnoevidencethat
patienttransmits
infection10daysafterfeverhasresolved.
ChildrenarerarelyaffectedbySARS.Todate,therehave
heentworeportedcasesottransmissionfromchildrento
adultsandnoreportottransmissionfromchildtochild.
Threeseparateepidemiologicalinvestigationshavenot
foundanyevidenceof
SARStransmissioninschools.
Furthermore,noevidenceofSARShasbeenfoundin
infantsofmotherswhowereinfectedduringpregnancy.
Internationalflightshavebeenassociatedwiththe
transmissionofSARSfromsymptomaticprobablecasesto
passengersorcrew.WHOrecommendsexitscreeningand
othermeasurestoreduceopportunitiesforfurther
internationalspreadassociatedwithairtravelduringthe
epidemicperiod.
andsharingof
References
1.WHO(2003),WeeklyEpidemiologicalRecordNo.12,21March2003
2.WHO(2003),WorldHealthReport2003,Shapingthefuture.
3.WHO(2003),WeeklyEpidemiologicalRecordNo.43,24thOct.2003.
4.WHO(2009),WeeklyEpidemiologicalRecordNo.7,13thFeb.2009.
5.StephenJ.Mcpheeetal,(2010),CurrentMedicalDiagnosisand
Treatment,49thEd.ALangeMedicalPublication.
CORONAVIRUSDISEASE-19
Coronavirusdisease-2019(COVID-19)iscausedby
SARS-CoV-2,anewlyemergentcoronavirus,thatwasfirst
recognizedinWuhan,China,inDecember2019.Genetic
sequencingofthevirussuggeststhatitisabetacoronavirus
closelylinkedtoSARSvirus.Itisfromthefamilyofsingle-
strandedRNAvirus(tssRNA)withacrownlikeappearance
underanelectronicmicroscope,
60-140nmdiameter,containslargewidelyspreadclubor
petalshapedspikes.Althoughhightemperaturedecreases
thereplicationofthevirus,itcanresistthecoldtemperature.
Itissensitivetoultravioletrays,andiseffectivelyinactivated
bylipidsolventsincludingether(75percent),ethnol,
chlorine-containingdisinfectants,peroxyaceticacidand
chloroformexceptforchlorhexidine(1).
ThedynamicsofSARS-CoV-2arecurrentlyunknown,
butitisspeculatedthatithasananimalorigin.
Complications
Aswithanyviralpneumonia, pulmonary
ofapproximately
decompensationisthemostfearedproblem.ARDSoccursin
about16%patients,andabout20-30%ofpatientsrequire
intubationandmechanicalventilation.Sequelaeofintensive
careincludeinfectionwithnosocomialpathogens,tension
pneumothoraxfromventilationathighpeakpressures,and
non-cardiogenicpulmonaryedema.
Treatment
Severecasesrequireintensivesupport.Althoughanumber
differentagentsincludingribavirin(400-600mg/dand
4gd),lopinavir/ritonavir(400mg/100mg),interferontype1,
intravenousimmunoglobulin,andsystemiccortiocosteroids
wereusedtotreatSARSpatientsduringthe2003epidemic,the
treatmentefficacyofthesetherapeuticagentsremains
inconclusiveandfurtherresearchisneeded.Subsequent
studieswithribavirinshownoactivityagainstthevirusinvitro,
andaretrospectiveanalysisoftheepidemic
Suggestsworseoutcomesinpatientswhoreceivethedrug(5).
Prognosis
Globalscenario
InlateDecember2019,investigationofaclusterof
pneumoniacasesofunknownorigininWuhan,China,
resultedinidentificationofanovelcoronavirus.Thevirusis
distinctfrombothSevereAcuteRespiratorySyndrome
(SARS)coronavirusandMiddleEastRespiratorySyndrome
(MERS)coronavirus,althoughcloselyrelated.Early
epidemiologicalfindingssuggestthatthevirusismore
contagiousthanitspredecessors.SevereAcuteRespiratory
SyndromeCoronavirus-2(SARS-CoV-2)isanewly
identifiedpathogenanditisassumedthatthereisno
existinghumanimmunitytothevirus.Everyoneis
susceptible,althoughtheremayberiskfactorsthatincrease
anindividualsillnessseverity.
Toronto
Iheoverallmortalityrateofidentifiedcasesisabout
4.
Mortalityisage-related,rangingfromlessthan
17%in
persons
under24yearsofagetogreaterthan50%in
personsover65yearsofage.Poorprognostictactors
ncludeadvanced
age,chronichepatitisBinfectiontreated
amivudine,highinitialorhighpeaklactate
Endrogenaseconcentration,highneutrophilcounton
sentation,diabetesmellitus,acutekidneydisease,and
COunts
ofCD4andCD8onpresentation.Many
cinical
casesprobablygoundiagnosed.Seasonality,as
withintuenza,isnotestablished(5).
Prevention
ThediseasesinceitsfirstdetectioninChina,hasnow
spreadtoover200countries/territories.COVID-19was
declaredaPandemicbyWHOon11thMarch2020,
resultinginshiftoffocusfromChinatoEuropeandNorth
Americaandlaterontotheworld.AssuchWHOadvised
countriestotakeawhole-of-government,whole-of-society
approach,builtaroundacomprehensivestrategytoprevent
disease,savelivesandminimizetheeffect.Countriesclosed
theirbordersagainsttravelrelatedactivities(byair,road,
railwayorsea),andlockdownwasimposedtominimizethe
publicmovements.
thereis
novaccineagainstSARS,thepreventive
SuresforSARScontrolareappropriatedetectionand
otectivemeasureswhichinclude:
D
ompt identificationof
personswithSARS,their
movements
andcontacts

29. 19
22
EPDEMIOLOGY OFcOMMUNICABLE DISEASES
*
InIndla,theoutbreakofthediseasewasdeclar
OnDecember14th2020,anewstrainofCOVID-19virus
wasreportedfromUR.Itisspeculatedthatthenewstrainis
highlycontagious,about70percentmoretransmissiblethan
theoldvariant.TheUK
variantisnowreferredtoas
SARS-CoV-2VOC202012/01.Asof30thDecember2020,
theURvarianthasbeenreportedinfiveofthesixWHO
regions.Anothervariant,501Y.V2,wasreportedon18th
December2020,inSouthAfrica(2).Thereisnoclearevidence
otthisvariantcausingmoreseverediseaseorworseoutcomes.
Asof19thFebruary,2021,about11.08crorecaseswere
reportedgloballywith24,53,582deaths.About8.58crore
casesrecoveredandtherecoveryratewas77.4percent.USA
reportedthehighestnumberofcases(2.85crore,5.05lakh
deaths).followedbyBrazil(1crorecasesand2.43lakh
deaths),Russia(4.13crorecasesand82.3thousanddeaths),OR(4.08crorecasesand1.19lakhdeaths),andFrance(3.53crorecasesand83.3thousanddeaths)(5A).
epidemicandEpidemicDiseaseAct,1897
was
invoked
leadingtotemporaryclosureofeducational
religi
entertainmentandcommercialestablishments.AIls,
visasweresuspendedinMarch2020.On25thMarchst
theGovt.ofIndiadeclaredacountrywidelockdowntill
March,whichwasextendedupto14thApril2020T
lockdownwasfurtherextendedto3rdMay,
then
tunte
17thMay2020.Thiscovers4phasesoflockdowninthe
intry.ltwasfollowedbygradualun-lockdowninthecountry,
spre:
preadin6phases(onemontheach)upto30thNovember2020
Thegovernmentdividedallthedistrictsinto3
20nesbasedonthespreadofthevirus
-
green,redand
oranao
gezonewithrelaxationsapplieddaccordingly.Theredzonewas
furtherdividedintocontainmentzone
andbufferzone.For
expandingtheinfrastructure,COVID-19DedicatedHospitals
werecreated.Theyareasfollows(1)1,054Dedicated
COVIDHospitalsofabout1.81lakhbeds;(2)2,681DedicatedCOVIDHealthCareCentreswith150lakhbeds:(3)7,292COVIDCareCentreswith6.62lakhbeds.There
were9.96lakhdedicatedbedsason29.5.2020(5).
Maharashtra,Delhi,Kerala,AndhraPradesh,Karnataka
andTamilNaduweretheworsthitstatesofthecountry.Creationofpanicinlabourclassresultedinlargescale
movementofpeopleleavingtheplaceoftheirjobandmovingtotheirnativeplacewiththeirfamilies,creating
Whencomparedglobally,India'scasespermillion
populationwereamongstthelowestintheworld.Like-wisethenumberofdeathspermillionwasalsooneofthelowest,asshowninFig.1
andFig.2(3).
Thepandemichastaughttheworldthat"globalproblemrequiresglobalsolution".International
co-operationistherequirementoftheday.Whetherindetectionofvirusordevelopmentofvaccinesoractiononeconomicandsocialfronts.COVID-19
hasimposedmanyrestrictionsonourdailybehaviourwhetheritissocialdistancingorwearingmasks.Wehavealsodiscoveredthatwork-from-home-study-frorm-
home,andshop-from-home,
novisittomallsandmarketsareworkableconcepts.Ecommerce
portalswitnessedrecordtraftic.whichmaybecomeapermanentfeature(4).
chaos.
Ason19thFebruary,2021,therewere1.09millioncaseswith156,111deathsinthecountry.1.06millioncases
recoveredandtherecoveryratewas97.30percent.Thenewcasesperdaywereroundabout12,000(5A).
TheraceofvaccinehastouchedthefinishinglineandthefirstbatchofrecipientsreceivedthefirstdoseofvaccineinDecember2020.
By19thFebruary,
2021,10.1millionpersonshadreceived
vaccinationinIndia.
AarogyaSetuApp:AarogyaSetuAppwaslaunchedbytheGovernment
ofIndiaonthe2ndApril2020,and
15
availablein11languagesincludingHindiandEnglish.Itisoneofthemanylocation-based
surveillanceapp.tolettheuserscheckwhethertheyhavebeenincontactwithintectedpeoplebyusinglocation
andbluetoothdatatromSmartphones.Theapp.isavailableonbothAndroidandiOSdevices.Itasksasetofquestionstotheusertoidenurywhethertheyareattheriskofthecoronavirusintection.
INDIA
InIndia,thefirstcaseofCOVID-19
wasreportedon30thJanuary2020inKerala.IndiacurrentlyhasthelargestnumberofconfirmedcasesinAsia.Theperdaycasespeakedinmid-September2020withabout90,000reportedcases,andsincethenithascomedowntoabout12,000
casesperdayinFebruary2021.
90,000
85.853
1,800
1,753
80,000
1,600
1,571
1,52170,000
1,400 1,276
59,948
1,14160,000
54,106
1,200
50,000 45,781
46,978
1,000
40,000
800-
28,355
564600-
30,000
400
20,000
-
200112
10,000
7895
oL
IndiaRussia
BrazilFrance
0
ndiaRussiaItalyBrazilFranceUK USA
USA ItalyUK
FIG.2
Deathspermillion
populationamongst
thelowestintheworia
(19.02.2021)
FIG.
1
Casespermillionpopulationamongstthelowestintheworld
(19.02.2021)

30. COVID-19 193
Modeoftransmission(6)
gradualdeclineovertime.ThedurationofRT-PCRpositivity
generallyappearstobe1-2weeksforasymptomatic
persons,andupto3weeksormoreforpatientswithmildto
moderatedisease.InpatientswithsevereCOVID-19
disease,itcanbelonger(7).
TransmissionofSARS-CoV-2
canoccurthroughdirect,
indirector
closecontactwith
eatorydroplets,whichareexpelledwheninfectedan
coughs,sneezesortalks.Respiratorydropletsare
-10umindiameterwhereasdropletss5umindiameter
dropletnucleioraerosols.Respiratory
droplet
iransmissioncanoCCurwhenpersonisinclosecontact
aithin1metre)withaninfectedpersonwhohasrespiratory
SumptomsorwhoIStalking.Inthesecircumstances,
reSpiratorydropletsthatincludeviruscanreachthemouth,
noseoreyesofasusceptiblepersonandcanresultin
infection
Airbornetransmissionisdetinedasspreadofan
infectiousagentcausedbytransmissionofdropletnuclei
(aerosols)thatremainintectiouswhensuspendedinairover
longdistancesandtime.AirbornetransmissionofSARS-
CoV-2canoccurduringmedicalproceduresthatgenerate
aerosolsoritmayalsospreadinindoorsettingswithpoor
ventilation.Highvariabilityissuggestedbetweenindividuals
intermsofparticleemissionratespeech,withincreased
ratescorrelatewithincreasedamplitudeofvocalization(6).
infected
peoplethroughnu n
suchassalivaandrespiratory
secretionsortheir
AstudyofthefirstpatientsintheRepublicofKorea
showedthat9-13secondarycasesoccurredamong
householdcontacts.
Incubationperiod
2-14days
ClinicalspectrumofSARS-CoV-2infection
MostpatientswithCOVID-19predominantlyhaveea
respiratorytractinfectionassociated.However,inasmall
proportionofcases,theycanprogresstoamoresevereand
SystemicdiseasecharacterizedbytheAcuteRespiratory
DistressSyndrome(ARDS),sepsisandsepticshock,
multiorganfailure,includingacutekidneyinjuryandcardiac
injury(7,8).Thedefinitionofacase,acontact,andclinical
presentationandriskfactorsareasshowninTable1.Table2
showstheprogressofmilddiseasetoaseveredisease.
Fomitetransmissionispossible.Respiratorysecretionsor
dropletsexpelledbyinfectedpersonscancontaminate
surfacesandobjects,creatingfomites.ViableSARS-CoV-2
virusandorRNAdetectedbyRT-PCRcanbefoundon
thosesurfacesforperiodsrangingfromhourstodays,
dependingontheambient
temperatureandhumidity)andthetypeofsuríace.
Therefore,transmissionmayalsooccurindirectlythrough
touchingsurfacesintheimmediateenvironmentorobjects
contaminatedwithvirusfromaninfectedperson,followed
bytouchingmouth,eyesornose.
Casedefinitions
1.Suspectcase(9)
Apatientwithacuterespiratoryillness(feverandatleast
onesign/symptomofrespiratorydisease(e.g.,cough,
shortnessofbreath)),ANDahistoryoftraveltoorresidence
inacountry/areaorterritoryreportinglocaltransmissionof
COVID-19diseaseduringthe14dayspriortosymptom
onset
OR
environment(including
SARS-CoV-2
hasalsobeendetectedinotherbiological
samples,includingurineandfaecesofsomepatients.
iowever,therehavebeennopublishedreportsof
ransmissionofSARS-CoV-2throughfaecesorurine.
Apatient/healthcareworkerwithanyacuterespiratory
illnessANDhavingbeenincontactwithaconfirmed
COVID-19caseinthelast14dayspriortoonsetofsymptoms;
OR
Apatientwithsevereacuterespiratoryinfection(fever
andatleastonesign/symptomofrespiratorydisease(e.g.,
cough,shortnessofbreath))andrequiringhospitalization
andwithnootheretiologythatfullyexplainstheclinical
Periodofcommunicability
nowingwhenaninfectedpersoncanspreadCOVID-19
amportant.EvidencesuggeststhatCOVID-19canbe.
withnpeople.1-3daysbeforetheirsymptomsappear,
nthehighestviralloadsasmeasuredbyRI-PCK,
ervedaroundthedayofsymptomonset,followedbya
presentation;
OR
AcaseforwhomtestingforCOVID-19isinconclusive.
TABLE
1
SymptomsandriskfactorsassociatedwithCOVID-19:
P
calpresentation
Presentingsignsand
symptomsotCOVID-19varyt
Mostpersonsexperiencefever(83-99%)cough(59-82%),fatigue(44-70%),anorexia(40-84%1.short
breath(3140%),myalgias(11-35%).Othernonspecificsymptoms,suchassorethroat,nasalcongestion
sof
headache,diarrhoea,
nauseaandvomiting,havealsobeenreported.Loss
ofsmell(anosmia)
or
loS5ofte
lageusia)precedingtheonsetofrespiratorysymptomshasalsobeenreported.
Olderpeopleandimmunosuppressedpatientsinparficularmaypresentwithatypicalsymptoms
such
ae
reducedafertness,reducedmobility,diarrhoea,lossofappetite,delirium,andabsenceof
fevern
astatlgue
Symptomssuchasdyspnoea,fever,gastrointestinal(G)
symptomsorfatigueduetophysiologic
ada
pregnantwomen,adverse
pregnancyeyents,Ouet
diseasessucnasmalaria,mayoverlapwithsUmnt
COVID19
Childrenmightnothavereportedfeverorcoughastrequentlyasadults.
1
SKactors
tor
vere ge
morethan60years(increasingwithage)
Onderlyingnon-communicablediseasesNs)diabetesnypertensíon,cardiacdiseaAo
cerebrovasculardisease,chronickidneydiseaseimmunOsuppressionand
cancer
hav Oniclungdisease
highermortality.
Smoking
Isease
Se,
Source
ce7,8)

31. 194
EPIDEMIOLOGYOF
COMMUNICABLE
IDISEASES
TABLE2
Symptomaticpatients
(Table1)meetingthecasedefinitionforCOVID-19withoutevidence
viral
but
no
signs
COVID-19diseaseseverity
Adolescentoradultwithclinicalsignsofpneumonia(fever,cough,dyspnoea,fastbreathina)
h
ofseverepneumonia,includingSpO,2
90%onroomair.
Childwithclinicalsignsofnon-severepneumonia(coughordifficultybreathing+fastbreathinn.
chestindrawing)andnosignsofseverepneumonia.
Fastbreathing(inbreaths/min):
<<
2
months:260;2-1lmonths:250;1-5years:240.
Whilethediagnosiscanbemadeonclinicalgrounds;chestimaging(radiograph,CTscan,
ound)
Mild
disease
pneumoniaorhypoxia.
ModeratePneumonia
and/ordisease
Adolescentoradultwithclinicalsignsofpneumonia(fever,cough,dyspnoea,fastbreathing)plusono
air.
mayassistindiagnosisandidentifyorexcludepulnonarycomplications.
thefollowing:respiratoryrate>30breaths/min;severerespiratorydistress;orSpO,<90%
onroom
ing:
SevereSevere
diseasepneumonia
CentralcyanosisorSpO,<90%;severerespiratorydistress(e.g.tastbreathing.grunting,very
seuere
or
Childwithclinicalsignsofpneumonia(coughordifficultyinbreathing)tatleastoneofthefollowine
chestindrawing);generaldangersign:inabilitytobreastfeedordrink,lethargyorunconsciousness
convulsions.
onths:260;2-11months:250;1-5years:240.Fastbreathing(inbreaths/min):<!
Whilethediagnosiscanbemadeonclinicalgrounds;chestimaging(radiograph,CTscan,ultrasound)
mayassistindiagnosisandidentifyorexcludepulmonarycomplications.
AcuterespiratoryOnset:within1weekofaknownelinicalinsult(i.e.pneumonia)orneworworseningrespiratory
distresssyndromesymptoms.
(ARDS)
Critical
disease
Chestimaging:(radiograph,CTscan,orlungultrasound):bilateralopacities,notfullyexplainedby
volumeoverload,lobarorlungcollapse,ornodules.
Originofpulmonary
Needobjectiveassessment(e.g.echocardiography)toexcludehydrostaticcauseofinfiltrates/oedemaif
noriskfactorpresent.
Oxygenationimpairmentinadults:
MildARDS:200mmHg<Pa0,/FiO,s300mmHg(withPEEPorCPAP25cmH,0).
ModerateARDS:100mmHg<PaO/FiO,s200mmHg(withPEEP25cmH,O).
SevereARDS:Pa0/FiO,S100mmHg(withPEEP25cmH,O).
Oxygenationimpairmentinchildren:noteOlandOSI.UseOIwhenavailable.IfPaO,notavailable,weanFi0,tomaintainSpO,s97%tocalculateOSIorSpO,/FiO,ratio:
-Bilevel(NIVorCPAP)25cmH,Oviafullfacemask:PaO,/FiO,s300mmHgorSp0,/FiO,s264.
-MildARDS(invasivelyventilated):4SOI<8or5OSI<7.5.
-ModerateARDS(invasively
ventilated):8OI<16or
7.5sOSI<12.3.
-SevereARDS(invasivelyventilated):Ol216orOSI212.3.
filtrates:respiratoryfailurenotfullyexplainedbycardiacfailureorfluidoverload,
Critical
disease
Sepsis Adults:acutelife-threatening
organdysfunction
causedbyadysregulatedhostresponsetosuspectedor
proveninfection.Signsoforgandysfunctioninclude:alteredmentalstatus,difficultorfastbreathing.low
Oxygensaturation,reducedurineoutput,fastheartrate,weakpulse,coldextremitiesorlowbloodpressure,
skinmottling,laboratoryevidenceofcoagulopathy,
thrombocytopenia,
acidosis,highlactate,oor
hyperbilirubinaemia.
Children:suspectedorproven
infection
and22age-based
systemicinflammatoryresponsesyndrome
(SIRS)
criteria,'ofwhichonemustbeabnormaltemperature
orwhitebloodcellcount.Adults:persistenthypotensiondespitevolume
resuscitation,requiringvasopressorstomaintain
MAP265mmHgandserumlactatelevel>2mmol/L.Children:anyhypotension(SBP<5thcentileor>2SDbelownormalforage)ortwoorthreeottne
following:
alteredmentalstatus;bradycardiaortachycardia
(HR<90bpmor>160bpminintantsan
heartrate<
70bpmor>150bpminchildren);
prolongedcapillaryrefill(>2sec)orweakpulse;ias
breathing;mottledorcoolskinorpetechialorpurpuricrash;highlactate;reducedurineoutpu
hyperthermiaorhypothermia.
Septicshock
Othercomplications
thathavebeendescribedinCOvi-19patientsincludeacute,life-threatening
conditions
suchas:acutepulmonary
embolism,acutecoronary
syndrome,acutestrOkeand
delirium.Cinicalsuspicion
forthesecomplications
shouldbeheightenedwnenca
forCOVID-19
patients,andappropriatediagnosticandtreatment
protocols
available.aIfaltitudeishigherthan1000m,thenthecorrectionfactorshouldbecalculated
asfollows:
PaO./FiO,xbarometricpressure/760.
bWhenPaO,isnotavailable,
SpO/Fi0,s315suggests
ARDS(includinginnon-ventilatedpatients).
cOxygenation
Index(OI)isaninvasivemeasurement
oftheseverityofhypoxaemic
respiratoryfailure
andmaybeusedtopredictoutco
inpaediatric
patients.ItiscalculatedastollowS:percentage
orractionotinhaledoxygen
multipliedbythemeanairwaypressure
in
dividedbythepartialpressureofarterialoxygen
tinmmig).OXygen
saturationindex(OSI)isanon-invasive
measurement
andnaso
shown
tobeareliablesurrogate
marker
ofl
inchilarenandadultswithrespiratory
failure.
OSIreplacesPaO,withoxygensaturauo
measuredbypulseoximetry(SpO,)intheOlequation.
dTheSOFAscorerangesfrom0to24andincudespointsrelatedtoSixorgansystems:
respiratory
(hypoxaemiadefinedbylow
Pau
coagulation(lowplatelets);Iiver{hign
dilroncaraOvascar(nypotension);
centralnervous
svstem
(lowlevelofconsciousness
den
byGlasgowComaScale);andrenal(lowurineoutputOrnigncreatinine).Sepsisisdefined
buan
increaseinthesepsis-relatedSOFASCore
of22points.Assumethebaselinescoreis0itdataarenotavailable.eSIRScriteria:abnormaltemperature(>
38.5or
3btachycardiaforageor
bradycardia
forageif<lyear;tachypnoea1orag
needformechanicalventilation;abnormalwhitebloodcellcounttorageor>10%bands
ABBREVIATIONS
:BPbloodpressure;
bpmbeatsper
minueACOntinuous
positive
airwaypressure:CTcomputedtomogra
FiO.
fractionofinspiredoxygen;MAPmean
artertalPressure
oninvasiveventilation;
OIOxygenation
Index:OSIOxygenation
i
usingSp0,;PaO,partialpressure
arterialoxygen,
FpoSIveend-expiratorypressure;SBPsustolicbloodpressure:
SDstandarddeviation
SIRSsystemicinflammatoryresponse
syndrone,dorASEguenuaiorgan
talureassessment;
SpO,oxygensaturation.
mes
as
Source:(7,8)

32. COVI9 195
tvidieiiiisipnrne
2,
Laboratoryconfirmedcase(9
Oropharyngealsuab(e.g.throatswabTiltpatient's
headback70degrees.Rubswaboverhothtonsillarpillars
and
posteriororopharynxandavoidtouchingthetongue
feeth,andgums.Useonlysyntheticfihersvsabswithplastic
shafts.Donotusecalciumalginatesuwabsorswabswith
wOodenshafts.Placeswabsimmediatelyintosteriletubes
containing2-3mlofviraltransportmedia.
laboratoryconfirmation
ofCOVID-19
clinicalsignsandsymptoms.
A
personwith
infection,
irrespective
Definitionofcontact
A
contactisapersonhatisinvolvedinanyofthe
following
Dravidingdirectcarewithoutproperpersonalprotective
equipment(PPE)forCOVID-19patients
StauinginthesamecloseenvironmentofaCOVID-19
patient(includingworkplace,classroom,household,
gatherings).
Travellingtogetherincloseproximity(1m)witha
sumptomaticpersonwholatertestedpositivefor
Combinednasal&throatswabTitpatient'sheadback
T0degrees.Whilegentlyrotafingtheswab.insertswabless
thanoneinchintonostril(untilresistanceismetat
turbinates).Rotatetheswabseveraltimesagainstnasalwall
andrepeatinothernostrilusingthesameswab.Placetipot
theswabintosterileviraltransportmediatubeandcutotf
theapplicatorstick.Forthroatswab.takeasecanddry
polyesterswab,insertintomouth.andswabtheposterior
pharynxandtonsillarareas(avoidthetongue).Piacetipof
Swabintothesametubeandcutofftheapplicatortip.
COVID-19.
Highriskcontact
.Touchedbodyfluidsofthepatient(Respiratorytract
secretions,blood,vomit,saliva,urine,faeces)
Had
directphysicalcontactwiththebodyofthepatient
includingphysicalexaminationwithoutPPE.
Nasopharyngealswab:Tiltpatient'sheadback70degrees.
Insertflexibleswabthroughthenaresparalleltothepalate
(notupwards)untilresistanceisencounteredorthedistance
isequivalenttothatfromtheeartothenostrilofthepatient.
Gently,rubandrolltheswab.Leavetheswabinplacefor
severalsecondstoabsorbsecretionsbeforeremoving.
Touchedorcleanedthelinens,clothes,ordishesofthe
patient.
Livesinthesamehouseholdasthepatient.
Anyoneincloseproximity(within3ft)oftheconfirmed
casewithoutprecautions.
Cliniciansmayalsocollectlowerrespiratorytractsamples
whenthesearereadilyavailable(forexample,in
mechanicallyventilatedpatients).Inhospitalizedpatientsin
DedicatedCovidHospitals(severecaseswithconfirmed
COVID-19infection),repeatupperrespiratorytractsamples
shouldbecollectedtodemonstrateviralclearance.
Passengerincloseproximity(within3ft)ofa
conveyancewithasymptomaticpersonwholatertested
positiveforCOVID-19formorethan6hours.
Nucleicacidamplificationtesting(NAAT)for
SARS-CoV-2
Lowriskcontact Reversetranscriptasepolymerasechainreaction(RT
PCR)-baseddiagnostictests(whichdetectviralnucleic
acids)areconsideredthegoldstandardfordetectingcurrent
SARS-CoV-2infection.Morerecently,NAATshaveincluded
avarietyofadditionalplatforms(e.g..real-timeloop
mediatedisothermalamplitication).Clinically,theremaybe
awindowperiodofupto5daysafterexposurebeforeviral
nucleicacidscanbedetected.However,falsenegative
NAATresultscanalsooccuroutsideofthis5-daywindow.
Therefore,asinglenegativetestresuitdoesnotcompletely
excludeSARS-CoV-2infection
in
peoplewithahigh
likelihoodofiníectionbasedontheirexposurehistoryand/
ortheirclinicalpresentation,andrepeattestingusinga
NAATshouldbeconsidered.
Sharedthesamespace(Sameclassforschool/workedin
sameroom/similarandnothavingahighriskexposure
toconfirmedorsuspectcaseofCOVID-19).
iravelledinsameenvironment(bus/train/flight/any
modeoftransit)butnothavingahigh-riskexposure.
DiagnosisofCOVID-19
estingstrategiesforCovid-19diagnosisTherearetwo
pesoftestingsforSARS-CoV-2.(1)Diagnostictesting:
Itis
endedtoidentifycurrentinfectionattheindividuallevel
pertormedwhena
person
hassignsandsymptoms
sstentwithCOVID-19,
Orwhenaperson
1S
tomaticbuthasrecentknownorsuspectedexposure,
ocreeningtesting:Itisintendedtoidentifyinfected
SARS-CoV-2posesseveraldiagnosticchallenges,
includingpotentialydiscorcdantsheddingofvirusfromthe
upperversusthelowerrespiratorytract.Duetothehigh
specificityofNAAT,thereisnoneedtoobtainalower
respiratorytractsampletodiagnoseCOVID-19when
a
patientwithrecent
symptomshasapositiveNAAT Onanupperrespiratory
persons
whoareasymptomaticandwithoutknownor
oed
exposuretoSARS-CoV-2.Screeningfesting
1s
Ormedtoidentifypersonswhomaybecontagiousso
that
urescan
betaken.to
onsetofCOVID-19-compatible
thedisease
preventfurther
transmission
sample.
MOLECULAR
TEST
AntigentestingforSARS-CoV.2
WhencomparedwithRT-PCR-basedtests,
antigen-based
diagnostictests(whichdetectViralantigensinnasalor
nasopharyngealswabs,alsocalledRDI}areless
sensitive
buthaveasimilarlyhighspeciticity.Antigentestsperform
bestearlyinthecourseotsymptomaticSARS-CoV-2
infection,whentheviralloadisthoughttobehighest.When
apersonwhoisstronglysuspectedofhavingSARS-CoV-2
infectionreceivesànegativeresultonaninitialantigentest.
Hesni
ry samplecollectionmethod(7)
ALower
iratorytract
nchoalueolarlayage,trachealaspirate,sputum
ect2-3mLintoasterile,leak-pro,e
Sputum
Nasopharyngeal
swabandoropharyngeal
Oection
cuporsteriledrycontainer
PDerrespiratory
iract

33. 196
EPIDEMIOLOGYOF
cOMMUNICABLE DISEASES
repeattestingusingaNAATshouldbeconsidered.
Advantages
ofantigen-basedtestsaretheirlowcostand
rapidturnaround.Theavailabilityofimmediateresults
makesantigen-basedtestsanattractiveoptionforpoint-of
caretestinginhigh-riskcongregatesettingswhere
Preventingtransmission
iscritical.Antigen-basedtestsalsoLaboratory
examinations(10)
allowtorrepeattestingtoquicklyidentitypersonswitn
SARS-CoV-2infection.Currently,therearelimiteddatato
guidetheuseofrapidantigen
teststodetectorexclude
SARS-CoV-2infectioninasymptomatic
personsorto
determinewhetherapersonwhowaspreviouslycontirmea
tohaveSARS-CoV-2infectionisstillinfectious.
beperformedwithinthefirst24hoursin
thesuspect
every24/48hoursandcanbeusefulfor
patientfollnd
choiceofthesettingofmecnanicalventilation,and
for
the
indicationofpronepositioning.
In
theearlystageotthedisease,anormalordecro
totalwhitebloodcellcount(WBC)anda
ecreased
decrease
lymphocytecountcanbedemonstrated.
Interest
lymphopeniaappearStobeànegativeprognostic
tactor
Serologicorantibodytestingfordiagnosisof
SARS-CoV-2
Increasedvaluesofliver
enzymes,lactate
dehydrogenas
(LDH),muscle
enzymes,andCTeactiveproteincan
be
detected.
-Unlessabacterialoverlap,
anormal
procalcitoninvalue
UnlikeNAATsandantigentestsfor
SARS-CoV-2that
detectthepresenceofthevirus,serologicorantibody
tests
areintendedtoidentifypersonswithrecentorprior
SARS-CoV-2infection.
Becauseitmaytake2ldaysor
ongerafter
symptomonsetfor
seroconversionordetection
O
Immunoglobulin
lgMand/or
lgG
antibodies
to
SARS-CoV-2.Theuseof
serologictestingasthesolebasis
for
diagnosing
acute
SARS-CoV-2infection
isnot
recommended.
Giventhat
NAATsand
antigen
testsfor
SARS-CoV-2
occasionally
yield
falsenegative
results,
serologic
testshavebeenusedin
somesettings
asan
additional
diagnostic
testforpatients
whoare
strongly
suspected
tohave
SARS-CoV-2
infection.Using
serologyin
combination
witha
NAATtodetectlgGortotal
antibodies
3to4
weeksafter
onsetof
symptoms
maximizesthe
sensitivityand
specificity
todetect
past
intection
(10).
sfound.
The
elevated
neutrophil-to-lymphocyteratio
(NLR),
derivedNLRratio
(d-NLR)(neutrophilcount
divided
by
theresultofWBCcountminusneutrophilcount),and
platelet-to-lymphocyteratio,canbetheexpression
ofthe
inflammatorystorm.The
correctionofthese
indicesis
an
expressionofatavourabletrend.
-Increased
D-dimer.
Incriticalpatients,
D-dimervalue
is
increased,
blood
ymphocytes
decrease
persistently,and
laboratory
alterations
of
multiorgan
imbalance
(high
amylase,
coagulation
disordersetc.)are
found.
For
COVID-19patients
withseveredisease,
collect
blood
forblood
culture,
ideallypriortoinitiationof
antimicrobial
therapy.Dual
intection
withother
respiratory
intections
(viral,
bacterialand
fungal)havebeen
foundin
COVID-19
patients.
Depending
onlocal
epidemiologyand
cinical
symptoms,fest
for
other
potential
aefiologies,eg,
influenza,other
respiratory
viruses,
malaria,
dengue
rever,
typhoid
teveras
appropriate(7)CHEST
IMAGING
ChestX-ray
examination
Sincethe
disease
manifests
itselfas
pneumonia,
radiological
imaginghasa
fundamentalroleinthe
diagnostic
process,
management,and
follow-up.
Standard
radiographic
examination
(X-ray)ofthe
chesthasalow
sensitivityin
identitying
early
lung
changes
inthe
initial
stagesofthe
disease.
Atthis
stage,itcanbe
completely
negative.
Inthe
more
advanced
stagesof
intection,the,
chest
X-ray
examinafion
generally
shows
bilateral
multifocal
alveolar
opacities,
which
tend
to
confluence
uptothe
complete
opacityofthe
lung.
Pleural
effusion
canbe
associated,
Managementof
COVID-19
Inthe
containment
phase,
tobreak
the
chaino
transmission
of
COVID-19,
patients
with
suspected,o
Conirmed
disease
are
isolated.
Cases
canbe
managedat
ovid
Care
Centre,
First
Referral
Units,
Community
Healn
Centres
(CHC),
Sub-district
Hospitals,
District
H0splldiby
and
Medical
Colleges.
Detailed
clinical
historyis
taken
including
tnar
CO-morbidities.The
patient
is
followedup
aay
emperature,
vitalsand
oxygen
saturation
(SpO,.raie
Snouid
be
monitored
for
signs
and
symptoms
complications
that
should
prompt
urgent
rererrd.rad
Vitnrisk
tactorsfor
severe
illness
should
be
mon
OSeg,
given
the
possible
riskof
deterioratio.
Chest
computed
tomography
Giventhe
high
sensitivityofthe
method,chest
computed
tomography
(CT),in
particular
high-resolution
CT
(HRCT),
isthe
method
of
choicein
the
study
of
CovID-19
pneumonia,
evenin
the
initial
stages.
Several
non-specitic
HRCT
findings
and
patterns
canbe
found.
The
most
common
findings
are
multirocal
bilateralground
glass"
(GG)
areas
associated
with
consolidation
areaswith
patchy
distribution,
mainly
peripheral/subpleural
and
with
greater
involvementof
the
posterior
regions
and
lower
lobes.
Other
findings
arethe
"reversed
halo
sign
whichisa
focal
areaof
GG
delimitedbya
peripheral
ring
with
consolidation,
and
the
findingsof
cavitations,
calcifications,
Iymphadenopathies
and
pleural
elfusion
(10).
develop
any
worsening
symptoms5u
ceurein
Onrusion,
difticulty
breathing,
persistent
pain
or
presu
ano
the
chest,
bluish
coloration
of
taceups,
diately
ecreased
urine
output
etc.),
they
should
be
immedia
amited
toa
Dedicated
Covid
Health
Centre
or
Dedicateu
OVIa
ioSpital.
Children
with
mild
COVID-19
Shoua
monitorea
torsignsand
symptomsof
cinicadin
requing
urgent
re-evaluation.
These
includer
nTast
or
shallow
breathing
(for
intants:
grui
naoliy
to
breast-feed),
blue
lipsor
face,
chestpai
1as.t
interacting
when
awake,
inabilityto
drinkorkeep
aowdunt
of
An
algorithm
for
clinical
guidance
for
manageme
pressure,
new
confusion,
inabilityto
awakenno
d
Lung
ultrasound
Oltrasound
can
allow
evaluating
the
evolutionof
the
disease,
froma
focal
interstitial
pattern
upto
"white
lung"
with
evldence
oftenof
subpleural
consolidations.It
should
COVID-19
suspect/confirmed
caseisas
showni

34. COVID-19197
COVID-19Suspect/Confirmedcase
Stratificationonthebasisofdiseaseseverity
Mild
Moderate
Severe
(Feverand/or
uncomplicated
upperrespiratorytract
infection)withoutdyspnoea
orhypoxemia.
Pneumoinawithnosignsofseveredisease
RR224
minORSpO,<94%onroomair
Respiratorydistressrequiringmechanical
ventilation(non-invasive&invasive)
RR230/minORSpO,<90%onroomair
AdmittoCOVIDCareCenter AdmitinDCHC/DedicatedCOVIDHealthCenterAdmitin
DCH/DedicatedCOVIDHospital
.Contactanddroplet
precautions
Stricthandhygiene
Symptomaticmanagement
withadequatehydration
TabHCQ(400mgBDx
1
dayf/b400mgODx
4days)maybeconsidered|
inpatientswithhigh-risk
featurespreferablyafter
shiftingtoDCHC/DCH
ReferraltoDCHC/DCHis
indicatedif:RRz24min
ORSpO,<94%
onroomair.
OxygenSupport
TargetSp0,:92-96%(88-92%inpatientswithCOPD)
Preferreddeviceforoxygenation
:Non-rebreathing
facemask(ifHFNCorsimplenasalcannulaisused,
N.95orsurgicalmaskshouldappliedoverit)
Awakeproningmaybeusedinpatientswhocontinue
tohavehypoxemiadespiteoxygen>4L/min,
ifnocontraindications
Oxygenation
.CautioustrialofCPAPwithoro-nasal
mask/NIVwithhelmetinterface/HFNC,
ifworkofbreathingislow.Consider
intubation
ifworkofbreathingishigh/
nottoleratingNIV
.Lungprotectiveventilationstrategyby
ARDSnetprotocol
Prone
ventilationtobeconsideredwhen
thereisrefractoryhypoxemiaAnticoagulation
.ProphylacticdoseofLMWH/UFH,if
no
contraindications(e.g.enoxaparin40mgdailySC)3
Corticosteroids
-IVMethylprednisolone0.5-1mg/kg
or
Dexamethasone0.1-0.2mg/kgfor3-5days
Anticoagulation
.HighdoseprophylacticUFH
orLMWH
(e.g.enOxaparin40mgorU.5mg/kg
BDSC)itnotathighriskofbleeding
Corticosteroids
IVMethylprednisolone1-2mg/kgor
Dexamethasone0.2-0.4mg/kgfor5-7days
If
sepsis/septicshock:Manageasperexisting
protocol&localantibiogramn
Usesedationandnutritiontherapyasper
existingguidelines
|InvestigationalTherapies7
Antivirals
|1.Verymild/
pre-symptomatic/
asymptomaticcasescan
beconsideredforhome
isolationsubjectto
fulfillmentofconditions
stipulatedinguidelines
.Tab
HCQ(400mgBDx
1
dayf/b400mgODx4days)
ifnocontraindicationsandafterassessmentofECGfor
QTinterval,CRP,D-dimer&Ferritinevery48-72
hourly(ifavailable),CBCwithdifferentialcount,
absolutelymphocytecount,KFT/LFTtobedonedaily.
|InvestigationalTherapies
Testing:Whileattendingsuspectcases,asperaboveprotocolbasedonclinicalassessmenttesting||Discharge:Afterclinicalimprovement,
shallberesortedtoandifnegative,manageinnon-COVIDtacilityaccordingtoclinicaldiagnosIs.|dischargeasperreviseddischargepolicy!
2.High-riskpatientsforseverediseaseinclude:
Age60yearsormore
Hypertension,DM(diabetesmellitus)&other
immunocompromisedstates
Cerebrovasculardiseaseandobesityg
3.
LMWH:Lowmolecular
weightheparin
:ifno
contraindicationorhighrisk
ofbleeding;UFH:
Unfractionatedheparin
4.Higherchancesof
NTVfailure
|
5.Riskofbleeding:usevalidatedscorefor
assessingbleedingrisk(e.g.HAS-BLEDscore),
UseD-dimerandSICscoreforfurtherrisk
stratification(SICscore4portendshigh
thromboticrisk),
FollowAHA/ESCandISTHguidelinesincase
patientisonanti-plateletagents.
(BMI>25
kg/m)
Chroniclung/kidney/liverdisease
hvestigationaltherapies(Informedandshareddecisionmakingisessentialoeroreprescribinganyofthesetherapiesbesidestakinanoteof
nra-indicationsasmentionedinthedetalledguidelines).
6InjRemdesivir
200mgIVonday
Ifollowedby100mgIVdailyfornext.4dayslotal
daystherapy),inmoderatetoseverediseaseon
en
ormechanicalventilation(preferablyearlydisease),
ifnocontraindications,
Useofconvalescentplasma(200mlsingledose,mayberepeatedalterz4hrs,maybeconsideredinmoderatetoseverenat
Persistentorincreasingoxygenrequiremen
7Inj
Tocilizumab8mg/ka(max.doseS00mg
once;usualdose400
momay
becensldered
if
no
contraindications)inpati
Cane
aiseasewithprogressivelyincreasingoxygenrequirementsdespiteuseofcorticosteroidswithraicd
ns)inpatientsmoderate
e
repeatedafter12to24hours
IfnoImprovementoccurswiththetirstdose.
; iFIG.3
An
algorithm
for
elinlcalguldanceformanagementforCOVID-19suspected/confirmed
cases(lndia)
Source
(7)

35. 198
EPIDEMIOLOGYOFCOMMUNICABLE DISEASES
Preventionofcomplications
Interventions
Use
weaningprotocolsthatincludedailyassessmentforreadinesstobreathespontaneously
Minimizecontinuousorintermittentsedation,targetingspecitictilrationendpoinis
(lightsedationunless
Contraindicated)orwithdailyinterruptionofcontinuoussedativeintusions
Earlymobilization
Implementationoftheaboveasabundleofcare(mayalsoreducedelirium);suchastheAwakenino
and
BreathingCoordination,Deliriumassessment/management,andEarlymobility(ABCDE)
Oralintubationispreferabletonasalintubationinadolescentsandadults
Keeppatientinsemi-recumbentposition(headofbedelevation30-45°)
Useaclosedsuctioningsystem;periodicallydrainanddiscardcondensateintubing
Useanewventilatorcircuitforeachpatient;oncepatientisventilated,changecircuitifitissoiledor
damaged,butnotroutinely
Changeheatmoistureexchangerwhenitmalfunctions,whensoiled,orevery5-7days
Useachecklistwithcompletionverifiedbyareal-timeobserverasareminderofeachstepneeded
forsterileinsertionandasadailyremindertoremovecatheterifnolongerneeded
Anticipatedoutcome
Reducedaysofinvasive
mechanicalventilation
Reduceincidenceof
ventilator-associated
pneumonia
Reduceincidenceof
catheter-related
bloodstreaminfection
Reduceincidenceof
pressureulcers
Reduceincidenceof
stressulcersand
GIbleeding
Turnpatientevery2hours
Giveearlyenteralnutrition(within24-48hoursofadmission)
Administerhistamine-2receptorblockersorproton-pumpinhibitorsinpatientswithriskfactorsfor
GIbleeding.RiskfactorsforGlbleedingincludemechanicalventilationfor248hours,coagulopathy.
renalreplacementtherapy,liverdisease,multiplecomorbidities,andhigherorganfailurescore
Utilizede-escalationprotocolsassoonaspatientisclinicallystableandthereisnoevidenceofbacterialinfection
Exposepatienttoempiricantimicrobialtherapyfortheshortesttimepossible,topreventnephrotoxicity,cardiacandotherside-effectsfromunnecessaryantimicrobialuse
Do
notprescribeantibioticstosuspectedorconfirmedCOVID-19patientswithlowsuspicionofabacterialinfection,toavoidmoreshort-termside-effectsofantibioticsinpatientsandnegativelong-termconsequencesofincreasedantimicrobialresistance
Reducethedevelopment
ofantimicrobialresistance
Reducethedevelopment
ofadversedrugeffects
Promoteappropriate
antimicrobialprescribing
anduseduringthe
COVID-19pandemicC
Source:(7)
Preventionofcomplications
3.Tocilizumab(offlabel)maybeconsideredinpatients
withmoderatediseasewithprogressivelyincreasingoxygen
requirementsandinmechanicallyventilatedpatientsnot
improvingdespiteuseofsteroids.Longtermsafetydatain
COVID19remainslargelyunknown.Specialconsiderations
beforeitsuseinclude:presenceofraisedinflammatory
markers(e.g.,CRP,Ferritin,IL-6);patientsshouldbecarefully
monitored
infectionsandneutropenia;andthedrugiscontraindicated
in
PLHIV,thosewithactiveinfections(systemicbacteriafungal),tuberculosis,
activehepatitis,ANC<2000/mm
andPlateletcount<1,00,000/mm3.
ThedoseofTocilizumab1s
Bmg/kg(maximum800mgatonetime)givenslow100mlNSover1hour;dosecanberepeatedonce12to24hoursifneeded.
Implementationofthefollowinginterventionscanpreventcomplicationsassociatedwithcriticalillness.
Investigationaltherapies(7,11)
Atpresent,useofthesetherapiesisbasedonalimitedavailableevidence.Asthesituationevolves,andwhenmoredatabecomeavailable,theevidencewillbeaccordingly
incorporated,
andrecommendation
upgraded.Currently,
thesedrugsshouldonlybeusedinadefinedsubgroupofpatients:
postTocilizumabforsecondary
1.Remdesivir(underemergencyuseauthorization)mayybeconsideredinpatientswithmoderatedisease(thoseonoxygen)withnoneofthefollowingcontraindications:
AST/ALT>5timesupperlimitofnormal(ULN);severerenalimpairment(i.e.,eGFR<30ml/min/m2
or
hemodialysis);pregnancyorlactatingfemales;andchildren(<12yearsofage).Therecommendeddoseis200mg1V
onday1followedby100mgIVdailyfor4days(total5days).
2.Convalescentplasma(offlabel)maybeconsideredinpatientswithmoderatediseasewhoarenotimproving(oxygenrequirementisprogressivelyincreasing)despiteuseofsteroids.Specialpre-requisiteswhileconsideringconvalescentplasmainclude:ABOcompatibility
andcrossmatchingofthedonorplasma;neutralizingtiterofdonorplasmashouldbeabovethespecificthreshold.Ifthelatterisnotavailable,plasmaIgGtiter(againstS-proteinRBD)above1:640shouldbeused;recipientshouidbecloselymonitoredforseveralhoursposttransfusionforanytransfusion
relatedadverseevents;anduseshouldbeavoidedinpatientswithIgAdeficiencyorimmunoglobulin
allergy.Thedoseisvariablerangingfrom4to13ml/kg(usually200mlsingledosegivenslowlyovernotlessthan2hours.
Repurposedoroff-labeltherapies(7,11
Hydroxychloroquine
ThisdrughasdemonstaeInvitroactivityagainstSARS-CoV2andwasshownoibclinically
beneficial
inseveralsmallsinglecentersuthoughwithsignificant
limitations.Nonetheless
Sevexarge
observational
studieswithsevere
methodoolimitations
haveshownnoeffectonmortalityorclinically
meaningful
outcomes.Assuch,theevidenceas
behinditsuse
remainslimitedaswithotherdrugs3
shouldonlybeusedaftershareddecisionmakingwithtinpatientswhile
awaitingtheresultsofongoingstudiesthecasewithotherantivirals,thisdrugshouldbeuseda
earlyinthedisease
courseasposibletoachieveameaningtuleffects
andshouldbeavoidedinpatients
severe
disease.AnECGshouldideallybedonebetoprescribing
thedrugtomeasureQTcinterval(andFiCavoidedifQTcis>500ms).Thedoseis400mg
BDonday1followed
by400mgdailyfornext4days.
needfor

36. COViD-19 199
Thehe
permissiontouseazithromycinincombinationwith
hydroxychloroquineto
coronavirusinfectionhasbeenrolledback(11).
.
Performhandhygiene
followingallcontactswiththe
ill
persons.Refertopage145fordetails.Dryhandswithtowel.
.Respiratoryhygieneshouldbe
practicedbyall,
especially
illperson.
treatpatientswithsevere
HomecareforCOVID-19patients
Toensurebothsafetyandqualityofhealthcareofthe
natient,isolationandmonitoringispreferableinahospital
etting.However,forseveralreasons,insituationswhen
8.Discardthematerialusedtocoverthemouthandnose
orcleanthemappropriately.
9.Avoiddirectcontactwithbodyfluid,particularlyoral
set
inpatientcareisnotavailableorincaseofinformedrefusal
forhospitalization,patientswithmildsymptomsandwithout
chroniclung,heartorrenaldiseasesmaybecaredforinthe
homeenvironment.Thesameprincipleofcareappliesto
sumptomaticpatientsnolongerrequiringhospitalization.
Thepatientandfamilyshouldbeprovidedwithongoing
support,educationandmonitoring.Theyshouldadhereto
the
followingrecommendations(12)
1.Placethepatientinawell-ventilatedsingleroom.
2.Limitthenumberofcaretakersofthepatient,ideally
assignonepersonwhoisinagoodhealthwithoutrisk
conditions.Novisitors.
andnasalsecretions.
10.Cleananddisinfectfrequentlytouchedsurfacessuchas
bedsidetables,bedframes,andotherbedroomfurniture
dailywithhouseholddisinfectantcontainingdiluted
bleach.
11.Cleanbathroomandtoiletsurfacesoncedaily.
12.Cleanclothesandbedclothes,bathandhandtowelsetc.
13.Personswithsymptomsshouldremainathomeuntil
theirsymptomsareresolvedbasedoneitherclinical
and/orlaboratoryfindings(twonegativeRT-PCRtestsat
least24hoursapart).
14.Allhouseholdmembersshouldbeconsideredcontacts
andtheirhealthshouldbemonitoredforrespiratory
infection,fever,cough,sorethroat,difficultbreathing.
15.Useofpulseoximetertomonitoroxygensaturation.
3.Householdmembersshouldstayinadifferentroomor,if
thatisnotpossible,maintainadistanceofatleast
1m
fromtheillperson(e.g.sleepinaseparatebed).
4.Limitthemovementofthepatientandminimizeshared
space.Ensurethatsharedspaces(e.g.kitchen,
bathroom)arewellventilated(e.g.keepwindowsopen).
5.Thecaregivershouldwearamedicalmaskfittedtightly
tothefacewheninthesameroomwiththe
illperson.
Masksshouldnotbetouchedorhandledduringuse.If
themaskgetswetordirtywithsecretions,itmustbe
changedimmediately.Discardthemaskafteruseand
performhandhygieneafterremovalofthemask.
Pulseoximeter:It
isacompactportabledevice,measures
arterialbloodoxygensaturation(SpO,),heartrateandsignal
strength.Measuringrange
(minimumgraduation
1percent),heartrate
-20to250beats
perminute(minimumgraduation
1beatperminute).
SpO,30to100percent
Reviseddischargepoliçyforhospitalizedpatients
TherecommendationofGovernmentofIndiaonthe
dischargepolicyissummarizedandisasshowninthe
algorithminFig.4.
ConfirmedCOVID-19case
VeryMild/Mild/
Presymptomatic"
Moderate** Severe**
Fever
resolvedwithin
3days
and
oxygensaturation
maintainedwithoutsupport
Symptomsnot
resolvedanddemand
ofoxygentherapy
Dischargeonlyafter
.Clinicalrecovery
.Patienttested
negativeonceby
RT-PCR(after
resolutionof
Dischargeafter10days
Ot
symptomonsetand
nofeverfor3days
continues
Dischargeafter10daysof
Symptomonset
Dischargeonlyafter
Resolutionof
clinicalsymptoms
Abilitytomaintain
oxygensaturation
for3consecutivedays
symptoms)
Absence
offeverwithout
antipyretics
Resolutionofbreathlessness
No
oxygenrequirement
NO
RT-PCRtestrequiredbeforedischarge
Atthetimeofdischarge,thepatient
willbeadvisedtoisolatehimselfathome
andself-monitortheirhealthforfurther
7days
**Including
immunocompromised
(HIVpatients,transplant
recipients,malignancy)Clinical
categorizationof
patientsasperguidelines
FIG.4
Revised
dischargepolicyforCOVID-19
Source:114)

37. 200
EPIDEMIOLOGY OF
COMMUNICABLE DISEASES
3.Inhealth-carefacilityseting
Thefirstfollow-upvisit(physical/telephonic)should
h-
within
7daysafterdischarge,prelerablyatthehospita
wherehe/sheunderwentIreatment.
PostCOVID-19managementprotocol(15)
AfteracuteCOVID-19illness,recoveredpatientsmay
continuetoreportwidevarietyofsignsandsymptoms
includingfatigue,bodyache,cough,sorethroat,difficultyin
breathingetc.Aholisticapproachisrequiredfortollow-Up
careandwell-beingofallpost-COVID-19recovering
patients.Therecoveryperiodislikelytobelonger1or
patientswhosufferedmoresevereformofthediseaseand
thosewithpre-existingillness.
.Subsequent
trealment/follow-upvisitsmaybewith
nearestqualifiedallopathic/AYUSHpractilioner/medical
facilityofothersystemsofmedicine.Poly-therapyis
to
beavoidedduefopotenlialtorunknowndrug-drua
interaction,whichmayleadtoSeriousAdverseEvents
(SAE)orAdverseEffects(AE).
Thepatientswhohadundergonehomeisolation,iftheu
complainofpersistingsymptoms,willvisitthenearest
healthfacility.
Severecasesrequiringcriticalcaresupportwillrequire
morestringent
follow-up.
the
POST-COVIDFOLLOW-UPPROTOCOL
1.Atindividuallevel
ContinueCOVIDappropriatebehaviour(useofmask,
handandrespiratoryhygiene,physicaldistancing).
Drinkadequateamountof
warmwater(ifnotcontra
indicated) PublichealthsurveillanceforCOVID-19(13)
Takeimmunitypromoting
AYUSHmedicine,tobe
practicedandprescribedbyaqualifiedpractitionerof
AYUSH.
TheaimofnationalsurveillanceforCOVID-19isto
enablepublichealthauthoriliestoreducetransmissionof
SARS-CoV-2,therebylimitingassociatedmorbidityand
mortality.Ifhealthpermits,regularhouseholdworktobedone.
Professionalworktoberesumedingradedmanner.
Mild/moderateexercise
TheobjectivesofCOVID-19surveillanceareto
rapiddetection,Enable
isolation,testing,and
Dailypracticeofyogasana,pranayamaand
meditation,asmuchashealthpermitsorasprescribed.
Breathingexercisesasprescribedbytreating
physician.
Dailymorningoreveningwalkatacomfortablepace
astolerated.
managementofcases
Detectandcontainclustersandoutbreaks,especially
amongvulnerablepopulations
ldentify,follow-upandquarantinecontacts
Guidetheimplementationandadjustmentoftargetted
controlmeasures,whileenablingsaleresumptionof
economicandsocialactivities
Balancednutritiousdiet,preferablyeasytodigestfreshly
cookedsoftdiet.
Haveadequatesleepandrest.
Avoidsmokingandconsumptionofalcohol.
TakeregularmedicationsasadvisedforCOVIDandalso
formanagingcomorbidities,ifany.Doctortobealways
informedaboutallmedicinesthattheindividualistaking
(allopathic/AYUSH)soastoavoidprescription
Evaluatetheimpactofthepandemiconhealthcare
systemsandsociety
Monitorlongertermepidemiologicirendsandevolution
ofSARS-CoV-2virusandmonitortrendsinCOVID-19
deaths
Contributetotheunderstandingoftheco-circulationof
SARS-CoV-2virus,iníluenzaandotherrespiratory
viruses,andotherpathogens.
interaction.
Self-healthmonitoringathome-temperature,blood
pressure,bloodsugar(especially,ifdiabetic),pulse
Oximetryetc.(ifmedicallyadvised)
Ifthereispersistentdrycough/sorethroat,dosaline
garglesandtakesteaminhalation.Theadditionofherbs/
spicesforgargling/steaminhalationcanhelp.Cough
medications,shouldbetakenonadviceofmedical
doctororqualifiedpractitionerofAyush.
Lookforearlywarningsignslikehighgradefever,
breathlessness,SpO,<95%,unexplainedchestpain,
newonsetofconfusion,focalweakness.
Surveillanceapproaches
2.Atthelevelofcommunity
.Recoveredindividualstosharetheirpositiveexperiences
withtheirfriendsandrelativesusingsocialmedia,
communityleaders,opinionleaders,religiousleadersfor
creatingawareness,dispellingmythsandstigma.
Takesupportofcommunitybasedself-helpgroups,civil
societyorganizations,andqualifiedprofessionalsfor
coveryandrehabilitationprocess(medical,social,
occupational,livelihood).
Seekpsycho-socialsupportfrompeers,community
healthworkers,counsellor.lfrequiredseekmentalhealth
supportservice.
ParticipateingroupsessionsofYoga,Meditationetc.
whiletakingalldueprecautionslikephysicaldistancing.
Mostcountriesneedsignificantlystrengthenedsurveillans
capacitiestorapidlyidentifyandcareforcasesofCOVID-19,
traceandquarantinetheircontactsandmonitordiseasetrends
overtime.ComprehensivenationalsurveillanceforCOv
willrequiretheadaptationandreinforcement
otexistlng
nationalsystems,whereappropriate,andthescale-upo
additionalsurveillancecapacities,asneeded.Dg
1echnologiesforrapidreporting,contacttracingand
dalda
managementandanalysismaysupportthesecapacilies
Robustcomprehensivesurveillance,onceinplace,sto
0emaintainedeveninareaswheretransmissionhasbeen
Suppressedorcontrolled,eveniftherearefewornocases.
lts
criticalthatnewcasesandclustersofSARS-CoV-2intection
oe
detectedrapidlybeforeoutbreaksorwidespreadtransmissto
Occurs.ngoingsurveillanceforCOVID-19isalsoimportant
tounderstandlonger-termepidemiologicaltrends,Such
incidenceandmortalityamongdifferentagegroups.
nd
Populationgroupsareathigherriskforseveredisease
anu
death,andpotentialepidemiologicalchangesoverfime
KeyactionsforcomprehensiveCOVID-19surveillance
which
include:
existing
-Use,adaptation
surveillancesystems
andstrengtheningof

38. 201COVID-19
rengthen
laboratoryandtestingcapacities
adaptationandenhancementotpublichealthwork-
to
carryoutcaseinding,contacttracingand
Numberofconfirmeddeaths
Numberofprobabledeaths
Numberofindividualshospitalized(confirmedand
testing
probable)
Numberdischarged(confirmedandprobable)
Numberofhealthcareworkersinfected(contirmed
+
probable)asasubsetoftotalcasescount
Numberofhealthcareworkerswhodieddueto
COVID-19(confirmed+probable)asasubsetoftotal
IncluCOVID-19asamandatorynotifiabledisease
Implementimmediatereporting
Fstablishsystemstomonitorcontacttracingactivity.
tisimportanttomaintainroutinesyndromicsurveillance
forotherintectiousdiseases,especiallythosecausedby
respiratorypathogens,
Suchasinfluenzaandrespiratory
suncytialvirus,throughsurveillanceforinfluenza-like-illness
tsevereacuterespiratoryinfection(SARI),atypical
pneumoniaandunexplainedfever,withsamplingand
jaboratorytestingofallorasubsetofcases.Thisiscritical
forunderstandingtrends
inotherdiseaseswithsimilar
deathcount
Numberofpersonstested
NumberofpersonstestedbyPCR
Confirmed+probablecasesbyagegroupandsex
Confirmed+probabledeathsbyagegroupandsex
guide Categoriesfortransmissionpattern(16)to appropriatepublichealth
presentations
Dreparednessandclinicalmanagement.
WHOrecommendsusingthefollowingcategoriesto
describetransmissionpatternsatnationalandsub-national
levelstoguidedecisionsforpreparedness,readinessand
responseactivities.Thedefinitionsofcategoriesareas
showninTable4.
EssentialsurveillanceforCOVID-19
shouldbegeographically
Surveillance
comprehensive,andsurveillanceforvulnerableorhigh-risk
populationsshouldbeenhanced.Thiswillrequirea
combinationofsurveillancesystemsincludingcontact
tracingforalllevelsofthehealthcaresystem,atthe
communitylevel,inclosedresidentialsettingsandinother
vulnerablegroups.Table3showshowsurveillancesystems
canbecombinedacrossdifferentsites.
systems
Preventionofthedisease
Dogajkidoori,maskhaijaroori"isthesloganofthe
day.AlthoghthevaccineisnowavailableinIndia,itis
criticalthatpeopleshouldcontinuetofollowallthe"COVID
AppropriateBehaviour".Theyshouldusemask,maintaina
physicaldistanceofatleast6feetwheninpublicplace,not
touchnose,eyesandmouth,covermouthandnosewhile
coughingandsneezingandavoidspittinginopen,prompt
testingonobservingsymptoms,andisolationifhavingthe
diseaseorforcontactsquarantinefor14days.
Globalsurveillance
Theobjectivesoftheglobalsurveillanceareasfollows:
MonitortrendsinCOVID-19atnationalandgloballevels
Monitormortalitycausedby,andindirectlyassociated
with,COVID-19
WhileUKandUSAhaveemergedasthefirsttwo
countriesintheworldtolaunchtheCOVIDvaccine,India
hasalsolaunchedoneoftheworld'slargestCOVID
vaccinationdrive.Thisisthefirsttimethatavaccinefor
COVID-19hasbeendevelopedandlaunchedinthecountry.
Dryrunforthevacine:Thedryrunisamockdrilltotest
thelaidoutmechanismsforCOVID-19vaccinationrollout
inthehealthsystemandtoassesstheoperationalfeasibility
ofusingCO-WINapplicationinfieldenvironmentfor
planning,implementationandreportingattheblock,district
andstatelevels(17,18).
Estimatemorbidityandmortalityforhealthcareworkers
Assesstheimpactofcontrolmeasures.
Weekly
aggregatedreporting
Theaimofongoingweeklyaggregatereportingisto
00tainfurtherinformationonglobalCOVID-19trendsfor
Cnnancedanalysis.Thevariablesareasfollows(16):
Numberofconfirmedcases
Number
ofprobablecases
TABLE3
Surveillancesystemsacrossdifterentsites/contexts
Mortality
surveillance
System
Site
Context
Contact
tracing
Virologic
surveillance
Cluster
SerologicImmediate
investigations
surveillancecasenotification
Community
Prima
CareSites
non-sentinel
ILI/ARI)
Hospitals
non-sentinel
IL/SARI)
Sentinel
lLIARI
SARI
sites
Closed
settings
Health
care-associated
SARS-CoV-2
infection
Travellers
atpoints
ofentry
Including
butnot
liSource
(16)
mnitedtolong-termlivingfacilities,prisonsanddormitories.

39. 202
EPIDEMIOLOGY OFCOMMUNICABL.E DISEASES
TABLE4
Definitionofthecategoriesfortransmissionpallern
Categoryname
Definition
No(active)cases Nonewcasesdetectedforatleast28days(twotimesthemaximumincubationperiod),
inthepresenceofarobustsurvellancesystem.Thisimplesanear-zeroriskofinfection
forthegeneralpopulation.
Imported/Sporadiccases Casesdetectedinthepast14daysareallimported,sporadic(e.g.laboratoryacquiredor
zoonotic)orarealllinkedtoimported/sporadiccases,andtherearenoclearsignalsoffurther
ation.
locallyacquiredtransmission.Thisimpliesminimalriskofinfectionforthegeneralpopulation
Clustersofcases
Casesdetectedinthepast14daysarepredominantlylimitedtowell-definedclustersthat
2not
directlylinkedtoimportedcases,butwhicharealllinkedbytime,geographiclocation
and
commonexposures.Itisassumedthatthereareanumberotunidentifiedcasesinthearea.
Thisimpliesalowriskofinfectiontoothersinthewidercommunityifexposuretothese
clustersisavoided.
Communitytransmission
-
level1
(CT1)
Lowincidenceoflocallyacquiredwidelydispersedcasesdetectedinthepast14daysnotlinked
tospecificclusters;transmisionmaybefocussedincetainpopulationsub-groups.Lowriskof
infectionforthegeneralpopulation.
Moderateincidenceoflocallyacquiredwidelydispersedcasesdetectedinthepast14days:
transmissionlessfocussedincertainpopulationsub-groups.Moderateriskofinfectionforthe
generalpopulation..
Highincidenceoflocallyacquiredwidelydispersedcasesinthepast14days;transmissionnot
focussedincertainpopulationsub-groups.Highriskofiniectionforthegeneralpopulation.
Communitytransmission
-level2
(CT2)
Communitytransmission-level3
(CT3)
Communitytransmission
-level4
(CT4)
Veryhighincidenceoflocallyacquiredwidelydispersedcasesinthepast14days.Veryhighrisk
ofinfectionforthegeneralpopulation.
Source:(16)
VaccinationforCOVID-19isvoluntary.However,itis
advisabletoreceivethecompletescheduleofCOVID-19
vaccineforprotectingone-selfagainstthisdiseaseandalsoto
limitthespreadofthisdiseasetotheclosecontacts.Itis
advisabletoreceivecompleteschedule
irrespectiveofpasthistoryofinfectionwithCOVID-19.This
willhelpindevelopingastrongimmuneresponseagainstthe
disease.PersonwithconfirmedorsuspectedCOVID-19
infectionmayincreasetheriskofspreadingthesametoothers
atvaccinationsite.Forthisreason,infectedindividualsshould
defervaccinationfor14daysaftersymptomsresolution.
AnyofthefollowingmentionedIDwithPhotomaybe
producedatthetimeofregistration:AadharCard.Driving
License,HealthInsuranceSmartCardissuedunderthescheme
ofMinistryofLabour,MGNREGAJobCard,officialidentity
cardsissuedtoMPs/MLAs/MLCs,PANCard,passbooksissued
bybank/postOffice,passport.pensiondocument,service
identitycardwithphotographissuedtoemployeesbyCentral'
StateGovt./PSUs/PublicLimitedCompanies,VoterIDand
SmartcardissuedbyRGIunderNPR.
COVIDvaccine
Followingonlineregistration,beneficiarywilreceive
SMSontheirregisteredmobilenumberfortheduedate,
place,andtimeofvaccination.Ongettingduedoseot
COVID-19vaccine,thebeneficiarywillreceiveSMSontheir
registeredmobilenumber.Afteralldosesofvaccineare
administered,aQRcodebasedcertificate
willalsobesentto
theregisteredmobilenumberofthebeneficiary.
Basedonthepotentialavailabilityofvaccinesthe
Governmentoflndiahasselectedtheprioritygroupswho
arevaccinatedonpriorityastheyareathigherrisk.Thefirst
groupincludeshealthcareworkersbecausetheyareathigh
riskofcontractingtheinfectionandprotectingthemhelpsto
sustainessentialhealthservices.Thevaccinationoffrontline
workers(police,home-guard,municipalworker,armed
forcesetc.)willhelpinreducingthesocietalandeconomic
impactbyreducingCOVID-19mortalities.Thenextgroupto
receiveCOVID-19vaccinewillbepersonsover50yearsof
ageandpersonsunder50yearswithcomorbidconditions
becausethereishighmortalityinthiscategory.Thereason
forinciudingmorethan50yearsofagegroupforvaccination
isthatitwillbeabletocover78%ofpersonshavingco-
morbiditiesandtherebyreducemortalityonaccountof
COVID-19.Morethan50yearsofagegroupisdividedinto
twosub-groups.Onesub-groupis60yearsandabove,they
willbevaccinatedfirst.Secondsub-groupisbetween50to
60yearsagegroup,theywillbevaccinatedafterthefirstsub
groupiscOvered.Insubsequentphasesthevaccinewillbe
giventotheremainingpersons.Only100personswillbe
vaccinatedateachdesignatedvaccinationsiteperday.
Thevaccinationmaynotbesequential.
Itcangoin
parallelforallbeneficiariesdependingontheavailabilityof
thevaccine.PhotoIDisamustforbothregistralionand
verificationofbeneficiaryatsessionsitetoensurethatthe
intendedpersonisvaccinated,
Itmustbeensuredthattheentirescheduleofvaccination
is
completedbyonlyonetypeofvaccine,asditteren
COVID-19vaccinesarenotinterchangeable.
Vaccine
Thevaccinesapprovedforpublicuseare:RNA
OzinameranfromPfizer-BioN
Tech,andmRNA-l2i5ro
Oena;conventionalinactivatecdvaccines
(BBIBP-LO
romSinopharmaandCoronavacfromSinovac)andvirat
ectorvaccines(Gam-COVID.VacfromGamaleyaKesearc
nstiluteandAZD1222fromUniversityofOxfordandAstra
Zeneca).
adng
coronavaccinecontendersinIndiahave
Deengrantedapprovalforrestricteduse.OxfordAstraLeneca
oronavirusvaccine"Covishield",manufacturedbyseru
InstituleofIndia,PuneandBharatBiotech's
COVIDvaccin
"Covaxin"(approvedforemergencyuseauthorization).
rersonswhoaretemporarilynoteligibletogetthe
vaccineare(19)
:
aPersonsshowlngactivesymptomsofSARS-CoV
infection;

40. CoVID19 203
thl
COVID-19patientswhohavebeengivenanti-SARS-CoV-2
monoclonalantibodiesOrconvalescentplasma;
ic)Thevaccineshouldbegivenwithcautiontopersons
withahistoryofanybleedingorcoagulationdisorder
plateletdisorder,clotting
coagulopathy;and
td)Actuallyunwellandhospitalizedpatients(withor
withoutintensivecare)duetoanyillness.
5.Personswith
immunodeficiencyorHIVandpatientson
immunosupprescentsduetoanyconditioncannotbe
administeredtheCovaxin
PeoplewhoarereceivingBharatBiotech'sCovaxinwillbe
requiredtosignaconsentformwhichassurestherecipients
medicalcareandcompensation
ifanyadverseeventisftound
linkedtothevaccine.
Itisbecausethevaccinegotrestricted
approvalbytheDrugsControllerGeneralofIndia"in
emergencysituationinpublicinterestasanabundant
precaution,inclinicaltrialmode,tohavemoreoptions,
especiallyincaseofinfectionbymutantstrainsThe"clinical
trialmode"isbecausephase-IIIclinicaltrials,thatareessential
toestablishefficacy,arestillongoing.Therecipientswillbe
monitoredmorecloselyinatypeof"openlabeltrial.
IncaseofCovishield,phase-IItrialwereconductedin
August2020inUKandBrazil,wherethecombinedefficacy
ofthetwotrialswasfoundtobe70percenteffective.While
bridgetrialsforCovishieldarestillongoing
inIndia,the
regulatorlookedatinternationaldatatoestablishsatetyand
efficacy.Sonoinformalconsentissought(19).
factordeficiencyOr
PersonswithapasthistoryofCOVID-19infectioncanbe
administeredthevaccine.Personswithahistoryofchronic
andcomorbidities(cardiac,
disease
Dulmonary,andmetabolic)areeligibleforthevaccine
althoughefficiencyofthevaccinemaybelessinthese
patients.Peopletakingthevaccineshouldavoidtobacco
andalcohol.Thevaccinesarenotinterchangeable.
neurological,
Covishieldvaccine(19)
Covishieldvaccineisarecombinantchimpanzee
adenovirusvectorvaccine,administeredintramuscularlyin
deltoidmuscle.ivenintwodoses,28daysapart.The
protectivelevelofantibodiesaregenerallydevelopedtwo
weeksafterthe2nddoseofthevaccine.Thevaccinehas
beenapprovedforindividuals18yearsofageandabove.
Tobestoredat2-8°C.
InIndiavaccinationisnotmandatory.But
ifyouchoose
togetvaccinated,youcannotchoosewhichvaccineyouwill
get.Youwillbevaccinatedbythevaccinethatisavailableat
thesite.16thJanuary,2021isthehistoricaldaywhenIndia
launchedthevaccinationdrive.
Sideeffects Pfizer-BioNtechCOVID-19Vaccine(20)
ThecommonsideeffectswithCovishieldvaccineare
injectionsitepainandtenderness,headache,fatigue,myalgia,
discomfort,pyrexia,chillsandnausea.Veryrareeventsof
demyelinationdisorderhavebeenreportedfollowingvaccine
"withoutthecausalrelationshipestablishment".
ItisamessengerRNAvaccinewith95percentefficacy.
People16yearsandolderareeligibleforthevaccine
administeredintwodosesintramuscularly,3weeksapart.
It
isauthorizedforemergencyuse.
Itisnotinterchangeable.
Storageisat-70°C.
Contraindications:(a)historyof
severeallergicreactioon
afterthepreviousdoseofthisvaccine:(b)hadasevere
reactiontoanyingredientofthisvaccine.
Contraindications
1.Thosebelow18yearsofage;
2.Pregnantandlactatingmothers;
3.Thosewithallergicreactiontovaccine,plasmacentrical
productsandnotablefoodallergies;
AnyonewhohashadadversereactiontocOVID-19
vaccineearlier;and
5.PersonswithimmunodeficiencyorHIVandpatientson
immunosupprescentsduetoanyconditioncannotbe
administeredtheCovidvaccine.
Beforetakingthevaccinetheprovidermustknowthe
medicalhistoryofthe
personanyallergy,fever,bleeding
disorder
ifany,ortakingbloodthinner,ifthepersonis
immunocompromisedoronamedicinethataftectsimmune
system,pregnancyandbreast-feeding,andhavereceived
anotherCOVID-19vaccine.
Sideeffects:Injectionsitepain,tiredness,headache
musclepain,chills,jointpain,tever,injectionsiteswelling
andredness,nausea,teelingunwell,swollenlymphnodes.
Thereareremotechancesofsevereallergicreaction(within
afewminutestoonehouraftergettingthedose).
Covaxinvaccine(19)
TheBharatBiotech'svaccine,developedincollaboration
with1CMRandNIVPune,isawholevirioninactivated
coronavirusvaccine.
Itisgiven
intramuscularlyindeltoid
muscleintwodoses28daysapart,topersonsabove
18yearsofage.Thevaccineshouldbestoredat2-8C.
ModernaCOVID-19Vaccine(21)
ItisamessengerRNAvaccine,withefticacyofabout
94.1percent,meantforpeople18yearsofageandabove,
twodosesgivenintramuscularly
1monthapart.Itshouldbe
storedbetween25°Cand-15°Ctemperature
Thevaccineprovidermustknowaboutthehistoryof
allergies,fever,bleedingdisordersorhistoryoftakingblood
thinner,pregnancy
andbreast-teedinginmothers,historyof
takinganotherCOVID-19vaccineandiftherecipientis
immunocompromised.
Sideeffects
ThecommonsideeffectsfollowingCovaxinareinjection
Sitepain,fatigue,fever,headache,bodyache,nausea,
abdominalpain,dizziness,sweating,andcoldandcough.
Contraindications
1
Thosebelow18yearsofage;
2.Pregnantandlactatingmothers;
5
Thosewithallergicreactiontovaccine,plasmacentrical
productsandnotablefoodallergies;
AnyonewhohashadadversereactiontoCOVID-19
vaccineearlier,and
Sideeffects:Sideeffectsreportedare(a)injectionsite
reactionsarepain,redness,swelling,tenderness;(b)general
sideeffectsaretatigue,headache,musclepain,jointpain,
vomiting,andfever.Severesideeffectsaredifficultyin
breathing,swellingoftaceandthroat,fastheartbeat,bad
rashalloverthebody,dizzinessandweakness.

41. 204 EPIDEMIOLOGYOFCOMMUNICABLE DISEASES
meninges,bonesandjoints,lymphglands,skinandother
tissuesofthebody.Thedisease1susuallychronic
with
varyingclinicalmanifestations.Ihediseasealsoaffects
animalslikecattle;thisisknownas"bovinetuberculosis"
whichmaysometimesbecommunicatedtoman.Pulmonart,
tuberculosis,themostimportantformoftuberculosiswhich
affectsman,willbeconsideredhere.
COVID-19deadbodymanagement
Allstaffidentifiedtohandledeadbodiesintheisolation
area,mortuary,ambulanceandthoseworkersinthe
crematorium/burialgroundshouldbetrainedintheinfection
preventioncontrolpractices.Thehealthworkerattendingto
thedeadbodyshouldperformhandhygiene,ensureproper
useofPPE.Plugoral,nasalorificesofthedeadbodyto
preventleakageofbodyfluids.Placethebodyinleak-proot
plasticbodybag.Theexteriorofthebodybagbe
decontaminatedwith1percenthypochlorite.Thebodybag
canbewrappedwithamortuarysheetorsheetprovidedby
thefamilymembers.Embalmingofthedeadbodyshouldnot
beallowed.Autopsiesshouldbeavoided.Thecrematorium/
burialgroundstaffshouldbesensitizedthatCOVID-19does
notposeadditionalrisktothem.Viewingofthedeadbodyby
unzippingtheface,fortherelativestoseethebodyforonelast
timeisallowed.Bathing,kissing,hugging,etc.ofthedead
bodyshouldnotbeallowed.Religiousritualssuchasreading
fromreligiousscripts,sprinklingholywaterandanyotherlast
ritesthatdoesnotrequiretouchingofthebodycanbe
allowed.Largegatheringatthecrematorium/burialground
shouldbeavoided.Thefuneralstaffandfamilymembers
shouldperformhandhygieneaftercremation/burial(22).
Problemstatement
WORLD
Tuberculosisremainsaworldwidepublichealthproblem
despitethefactthatthecausativeorganismwasdiscovered
morethan100yearsago
andhighlyeffectivedrugsand
vaccineareavailablemakingtuberculosisapreventable
and
curabledisease.Technologicallyadvancedcountrieshave
achievedspectacularresultsinthecontroloftuberculosis.
ThisdeclinestartedlongbeforetheadventofBCGor
chemotherapyandhasbeenattributedtochangesinthe
"non-specific"
improvementsinthestandardoflivingandthequalityoflife
ofthepeoplecoupledwiththeapplicationofavailable
technicalknowledgeandhealthresources.
determinantsofthediseasesuchas
Itisestimatedthataboutone-thirdofthecurrentglobal
populationisinfectedasymptomaticallywithtuberculosis,of
whom5-10percentwilldevelopclinicaldiseaseduring
theirlifetime(1).Mostnewcasesanddeathsoccurin
developingcountrieswhereinfectionisoftenacquiredin
childhood.Theannualriskoftuberculosisinfectioninhigh
burdencountriesisestimatedtobe0.5-2percent(2).
Patientswithinfectiouspulmonarytuberculosisdiseasecan
infect10-15personsinayear
Globally,anestimated10millionpeoplehadtuberculosis
intheyear2019,anumberthathasbeendecliningvery
slowlyinrecentyears.Therewereanestimated1.2million
TBdeathsamongHIV-negative
peopleandanadditional(areductionfrom1.7millioninyear2000),andanadditional208,000deathsamongHIV-positive
people.Menaged215yearsaccountedfor56percentofthepeoplewhodevelopedTBin2019;womenaccountedfor32percentandchildren(aged<15years)for12percent.Amongallthoseaffected,8.2percentwerepeoplelivingwithHIv(1
Globally,
theburdenofmultidrug-orrifampicin-resistantTB(MDR/RR-TB)
asashareofthenumberofTBcases
remainsstable.In2019,anestimated3.3percentofnewTBcasesand18percentofpreviouslytreatedcaseshadMDR/RR-TB.
Inabsolutenumbers,therewereanestimat
465,000
incident
8
percenthadmultidrug-resistant
TB.India(27percenChina(14percent)andRussianFederation(8percent)nathelargestburdens
References
1.NSBIBookShelf(2020),Features,evaluationandtreatmentofcorona
virus,lastupdated4thOct.2020.
2.WHO(2021),WHOhighlightsforSARS-CoV-2variants,Jan.2021.
3.Govt.ofIndia,Pressrelease,30thDec.2020.
4WHO(2020),Weeklyupdateofglobalcoronavirusimpactandimplications.
5.Govt.ofIndia,Pressrelease
5A.COVID-19,Coronauiruspandemic,19thFeb.,2021.
6
WHO(2020),TransmissionofSARS-CoV-2,
implicationsofinfection
prevention,precautions.
7.Govt,ofIndia(2020),ClinicalManagementProtocol:COVID-19,5thversion,3rdJuly2020.
8.WHO(2020),ClinicalManagementofCOVID-19,
27thMay2020.9Govt.ofIndia(2020),NationalCentreforDiseaseControl,updatedcasedefinitionandcontactcategories,DirectorGeneralofHealthServices.
10.NIH,COVID-19Treatmentguidelines,TestingforSARS-CoV-2infection,updated7thDec.2020.
11.ICMR(2020),ICMRrevisestreatmentprotocolforCOVID-19
patients.12WHO,Homecareforpatientswithsuspectednovalcoronainfectionpresentingwithmildsymptoms
andmanagement
ofcontacts,20thJan.2021.
13.WHO(2020),PublichealthguidelinesforCOVID-19
Interimguidance,16thDec.2020.
14.Govt.ofIndia(2020),Finalguidanceonmanagement
ofCOVID
cases.15.Govt.ofIndia(2020),PostCOVIDmanagement
protocol,13th
Sept.2020.
casesofrifampicin-resistantTB
16.WHO(2020),PublicHealthSurveillance,
16thDec.202017.Govt.ofIndia(2020),COVID-19
vaccinestrategy
communicationstrategy,helpushelpyou.
18.Govt.ofIndia(2020),Frequently
askedquestionsonCOVID-19vaccine,targetgroup
generalpublic.
19.Govt.ofIndia,Pressrelease.
20.Pfizer-BioNtech
COVID-19Vaccine
providerofthevaccine.
21.ModernaCOVID-19
Vaccine
factsheetforrecipientandproviderof
thevaccine
22.Govt.ofIndia(2020),COVID-19
:
Guidelines
ondeadbody
management,
15thMarch20020
Geographically,
mostpeoplewhodevelopedTBin
2019were
inSouth-East
Asia(44percent),Africa(25perC
andtheWestern
Pacific
(18percent).Indiawith26pe
factsheetforrecipient
andofthecasesisthehighest
burdencountryfollowe
cent
per centandChina8.4percent.The
incidence
rateatnational
level
variestromes
O0O00
5
tomore
than500new
andrelapsecasesper
population
peryear.Attheendof2019,tne
rden
whole,
most
WHO
regions
andmany
nigctoneso
d
as
aTUBERCULOSIS
Countries
were
notontracktoreachthe2020mies
theEndTBStrategy.
Tuberculosis
isaspeciticinfectious
disease
causedby
M.tuberculosis.
1The
diseaseprimarily
affects
lungs
and
causespulmonary
tuberculosis.
Itcanalsoaffect
intestine,
Globally,
7.1million
peopleplewithTBwerereportehavebeennewly
diagnosed
andnotified
in201
Despiteincrease
inTBnotifications,
therewasstillalarg
gap

42. TUBERCtH.OSiS 205
a0millionbetweenthe
numberofpeoplenewly
about
2.nd
reportedandthe10millionpeopleestimated
diagndavelopedTB.1hisgapis
due10acombinationof
rtingofpeoplediagnosedwithTBand
DevelopmentGoals(5).
Itfocusedonfiveindicators
to
neasuretheimplementationandimpactofTBcontrol.They
arecasedetection,treatmentsuccess,incidence.prevalence
death,
ThecoreofthestrategywasDOTS.TheWHO
nd
TBstrategy,adoptedbytheWorldHealthAssembly
in
ag2014,
isablueprintforcountriestoendtheTBepidemic
DydrivingdownTBdeaths,
incidenceandeliminating
catastrophiccosts.Itoutlinesglobalimpact
targetstoreduce
Bdeaths
by90percentandtocutnewcasesby80
percent
between2015and2030
accountecfor
morethan
percent),Nigeria(11
underdiagnosis(ifpeoplewithTBcannotaccesshealthcare
whentheydo).Fivecountries
halfoftheglobalgap.Theyare
percent),Indonesia(10per
not
diagnosed
are
India(17
cent),
Pakistan(8percenl)andthePhilippines(7percent).
hallyin2019,69percentofnotifiedTBpatientshad
andtoensurethatnofamilyis
burdenedwiththecostsduetoTB.EndingtheTBepidemic
yZ030
isamongthehealthtargetsofthenewlyadpted
SustainableDevelopmentGoals.WHOhasgoneonestep
Turtherandseta2035targetof95percentreduction
in
deathsanda90percentdeclineinTBincidencesimilarto
CurrentlevelsinlowTBincidencecountriestoday(6).For
furtherdetails,pleaserefertopage233.
HIVtestresult.Atotalof456,426TBcasesdocumented
peoplelivingwithHIv
timated
incidence).Otthese,88percentwereon
werereported(56percentof
antiretroviraltherapy(1).
Thelatestdatafor2018showstreatmentsuccessrate
of85percentforTB,57percentforMDR/RR-TB
and
76per
centfor
1
5patientslivingwithHIV
ThepreventivetreatmentforTBisexpanding,especially
inthe
priorityrisk
groupsofpeoplelivingwithHIVand
echildrenunder5yearsofage.However,mostpeopleeligible
for
TBpreventivetreatmentarenotacceptingit(3).
TheactualburdenofpaediatricTBisnotknowndueto
diagnosticdifficulties.Itisassumedthatabout10percentof
totalTBloadisfoundinchildren.Globally,about
1million
casesofpaediatric
TBareestimatedtooccureveryyear,with
morethan100,000deaths(4).ChildhooddeathsfromTB
areusuallycausedbymeningitisordisseminateddisease(2).
ThoughMDR-TBandXDR-TBisdocumentedamong
paediatricagegroups,therearenoestimatesofoverall
burdenbecauseofdiagnosticdifficultiesandexclusionof
childreninmostofthedrugresistantsurveys(4).
the
InSeptember2018,theUNGeneralAssemblyheldits
first-everhighlevelmeetingonTB.Theoutcomewasa
politicaldeclarationinwhichcommitmentstoSDOsand
EndTBStrategywerereaffirmedandnewonesadded.
GlobaltargetsforfundingtobemobilizedforTBprevention,
careandresearch,andforthenumberofpeopleto
be
treatedforTBinfectionanddisease,weresetforthefirst
time.Thetargetsareasfollows(1):
1.40millionpeopletreatedforTBfrom2018to2022,
including
-3.5millionchildren
1.5millionpeoplewithdrug-resistantTB,including
115,000children.
Inmanydevelopingcountries,acquireddrugresistance
remainshigh,becausenationaltuberculosiscontrol
programmesinthesecountrieshavenotbeenableto
achieveahighcurerateoveraverylongperiodoftime,
evenaftertheintroductionofshort-coursechemotherapy.
Poverty,economicrecession,malnutrition,overcrowding,
indoorairpollution,tobacco,alcoholabuseanddiabetes
makepopulationsmorevulnerabletotuberculosis.Increase
inhumanmigrationhasrapidlymixedinfectedwith
uninfectedcommunities.Tomakeglobalsituationworse,
tuberculosishasformedalethalcombinationwithHIO.
2.Atleast30millionpeopleprovidedwithTBpreventive
treatmentfrom2018to2022,including
-6millionpeoplelivingwithHIV
4millionchildrenunder5yearsofageand20million
peopleinotheragegroups,whoarehousehold
contactsofpeopleaffectedbyTB.
3.FundingofatleastUS$13billionperyearforuniversal
accesstoTBprevention,diagnosis,treatmentandcare
by2022.
4.FundingofatleastUS$2billionperyearforTBresearch
from2018to2022.
ThecurrentCOVID-19pandemicthreatenstoreverse
recentprogressinreducingtheglobalburdenofTBdisease.
TheglobalnumberofTBdeathscouldincreasebyaround
0.2-0.4millionin2020alone,ifhealthservicesaredisrupted.
TheWHOhassetInternationalStandardsfor
uberculosisCare.Thesestandardsareintendedtofacilitate
theeffectiveengagementofallcare-providersindelivering
hg-qualitycareforpatientsofallages,includingthose
with
smear-positive,
tuberculosis,drug-resistanttuberculosis,andtuberculosis
combined
withHIV
infection.ThebasicprinciplesofcareTOr
people
with,orsuspec
aeworldwide.Thestandardsareintendedtobe
Xementarytolocalandnationaltuberculosiscontrol
Tes
thatareconsistentwithWHOrecommendations.
heyarenotintendedtoreplacelocalguidelines.Thereare
Sandardsfordiagnosis,9standardsfortreatmentana
andardsforpublichealthresponsibilities.Pleasereterto
Opublication:WeeklyEpidemiologicalRecord,No.,
aed3rdFeb.2006forfurtherdetails.
smear-negative,extrapulmonary
INDIA
IndiaisthehighestTBburdencountryintheworldin
termsofabsolutenumberofincidentcasesthatoccureach
year.
Itaccountsfor26percentoftheestimatedglobal
incidentTBcasesin2019.Table
l
showstheburdenof
tuberculosisinIndia,theestimatedandreportedcasesfor
theyear2019(7,8).
AGEDISTRIBUTION
:OveralltheagedistributionofTB
diagnosedincidentcasesshowsapredominancein
adolescentandyoungadultagegroupsbetween15to
30yearsofage,indicatingongoingdiseasetransmissionas
showninFig.1.However,thereisawidevariationinthe
agedistributionpatternamongthestates.Insouthernstates
ofKerala,Karnataka,TamilNadu,AndhraPradeshandUTs
of.Puducherry,Lakshadweepthereisageneralelderly
prevalenceofTBtowardstheageS0+yearranges.Inother
statestheincidenceissimilartothatofthecountry.
ofhavingtuberculosisarethe
Orthepast
tuwodecades,nationalandinternational
Nop
TBstrategy
wasdesignedtochieveglobalTBtargets
SinTB
prevention,diagnosisandtreatmenthavebeen
equently
theStopTBStrategy(2006-2015).The
guided
Subseau DOTSstrategy(mid-1990until2005)and
U5
withinthecontextoftheMillennium

43. 206
EPIDEMIOLOGY OFCOMMUNICABLE DISEASES
TABLE
1 0-4
16,411 124,269
BurdenoftuberculosisinIndia(2019)
(Population:1,366million)
|
21
16,954 ,660
5-9
40,342 27,665
10-14
Number Rate(per100,000
(thousands)
15-119 1,09,942
99,370
population)
1,33.279
20-241.24,346
EstimatesofTBburden,2019
Incidence(Total)
Incidence(HIV+TB)
Incidence(MDR/RR-TB)
Mortality(HIVnegativeTB)
Mortality(HIVpositiveTBonly)
EstimatedproportionofTBcaseswith
MDR/RR-TB,"2019
25-29
1,06,783L 1.24,22
2640(1800-3630)193(132-266)
71(49-98)
124(73-189)
436(404-469)
9.5(6-14)
72,560 1,09,33
5.2(3.6-7.2)
9.1(5,3-14)
32(30-34)
0.69(0.44-1)
30-34
62,120L |1.12.48735-39
40-44
A8,821 1,08,820
45-49
47,327 1,15,269
42,474 1,09,065
2.8%(2.3-3.5)
14%(14-14)
50-54
Newcases
31,924
Previouslytreatedcases
Universalhealthcoverageandsocialprotection
TBtreatmentcoverage
55-59
,481
60-64
41,628 1,11.743
82%(60-120)| 25,11
65-69
70,931
(notified/estimatedincidence),2019
70-7 16.286 48,572
17%(12-24)|
TB
casefatalityratio
(estimatedmortality/estimatedincidence),2019 75+
,913 37,168
TBcasenotifications,2019
Totalcases
notified
Totalnewandrelapse
%testedwithrapiddiagnosticsattime
ofdiagnosis
%withknownHIVstatus
-opulmonary
-%bacteriologicallyconfirmed
%
childrenaged0-14years
T
150K 100K 50K OK 50K 100K 150K
2,404,815
2,162,323
17%|
80%
78%
57%
Female Male
FIG.
1
AgedistributionofTBcases,India(2019)
Source:(7)
7%
THEECONOMICANDSOCIALBURDENOFDISEASE
Besidesthediseaseburden,TBalsocausesanenormous
socio-economicburdentoIndia.TBprimarilyaffectspeople
intheirmostproductiveyearsoflife.Whiletwo-thirdsofthe
casesaremale,TBtakesdisproportionatelylargertoll
amongyoungfemales,withmorethan50percentoffemale
casesoccurringbeforetheageof34years(9).
Tuberculosiskillsmorewomeninreproductiveagegroup
thanallcausesofmaternalmortalitycombined,anditmay
createmoreorphansthananyotherinfectiousdisease.
Nearlyone-thirdoffemaleinfertilityinIndia,iscausedby
tuberculosis.Theindirectimpactoftuberculosisonchildren
isconsiderable,asnearly3lacschildrenoftuberculosis
patients,eitherleavetheschoolortakeupemploymentto
helpsupporttheirfamilies(6).Apatientoftuberculosis
takesanaverageofthreetofourmonthstorecuperate,
losingthatmuchincome.Thelossisdisastrousforthose
strugglingagainstpoverty.Theyaremostlikelytobe
detaultersoftreatment.Thevastmajority(morethan90per
cent)oftheeconomicburdenofTBinIndiaiscausedbythe
lossofliferatherthanmorbidity.
34%
owomen
%men
59%
TB/HIVcareinnewandrelapseTBpatients,2019
Number(%)|
PatientswithknownHIV-statuswhoareHIV-positive46,741
2.7%
-onantiretroviraltherapy 44,51795%|
|Drug-resistantTBcare,2019
%ofbacteriologicallyconfirmedTBcasestestedfor
ritampicinresistanceNew
cases
%ofbacteriologicallyconfirmedTBcasestestedfor
rifampicinresistance-Previouslytreated
cases
|
Laboratory-confirmedcases
Patientsstartedontreatment
MDR/RR-TBcasestestedforresistancetoanyfluoroquinolone36,748
77%
82%
MDR/RR-TB:66,255,XDR-TB":2,323
MDR/RR-TB°:56,569,XDR-TB":1,918
Treatmentsuccessrateandcohortsize
SuccessCohort
82%1,908,683
74%
Newandrelapsecasesregisteredin2018
Previouslytreatedcases,excludingrelapse,
registeredin2018
HIV-positiveTBcasesregisteredin2018
MDR/RR-TBcasesstartedonsecond-line
treatmentin2017
140,834
74% 32,493
InIndia,tuberculosisismainlyadiseaseofthepoor,The
majorityofitsvictimsaremigrantlabourers,slumdwellers,
residentsofbackwardareasandtribalpockets.Poor
living9
conditions,malnutrition,shantyhousingandovercrowading
arethemainreasonsforthespreadofthedisease(10).
49% 36,043|
36% 2,644
XDR-TBcasesstartedonsecond-line
treatmentin2017
TB
preventivetreatment,2019
%
of
HIV-positivepeople(newlyenrolledincare)
onpreventivetreatment
%ofchildren(aged<5)householdcontactsof
bacteriologically-confirmed
T5Bcasesonpreventivetreatment
Estimates
ofTBandMDR-TBburdenareproducedbyWHOIn
consultationwithcountries.Rangesrepresentuncertaintyintervals.
MDR
isTBresistanttorifampicinandisonlazid;RRlsTBresistantto
rifampicin.
Calculatedforpulmonarycasesonly,
IncludescaseswithunknownpreviousTBtreatmenthistory.
Includespatientsdlagnosedbefore2019andpalientswhowerenot
laboratory-confirmed,
HIVincreasesaperson'ssusceptibilitytotuberculosis
infection,andtuberculosisisoneoftheearles
opporlunisticdiseasetodevelopamongstpersonsintected
withHIV.Itincreasesmorbidityandmortalityin
infectedpersons.HIVisthemostpotentriskfactoro
progressionofTBinfectiontodisease.
45%|
33%(30-36)
Sincedeathrateisdecliningandthediseaseisshowing
cdeclineinyoungeragegroups,epidemiologists
beginningtothinkthatperhapswemayhavecrossed
peakofthesecularepidemiccurveandaresomewhere
thebeginningofthedeclininglimb.
are
ne
Source:(7,8)

44. 210
EPIDEMIOLOGY OFCOMMUNICABLE DISEASES
mycobacteriahavebeenisolatedfromman(19).Thesehave
beenclassifiedintofourgroups(i)photochromogens(e.g.
M.Kansasii);(ii)scotochromogens(e.g.,M.scrofulaceum)
(ii)non-photochromogens(e.g.,M.intercellulare))and,
(V)
rapidgrowers(e.g.,M.fortuitum).Allthesearemainly
saprophytic.Diseasesattributedtothemhaveresembled
pulmonarytuberculosisandchroniccervicallymphadenitis.
westernworldlongbeforetheadventotchemotherapeuti
drugs.Thishasbeenattributedtoimprovementsint
qualityoflife.
he
Modeoftransmission
Tuberculosisistransmittedmainlybydropletinfection
anddropletnucleigeneratedbysputum-positivepatients
withpulmonarytuberculosis.Totransmitinfection,the
particlesmustbefreshenoughtocarryaviableorganism.
Coughinggeneratesthelargestnumberotdropletsofall
sizes.Thefrequencyandvigourofcoughandtheventilation
oftheenvironmentinfluencetransmissionofinfection.
Tuberculosisisnottransmittedbytomites,5uchasdishes
andotherarticlesusedbythepatients.Sterilizationofthese
articlesisthereforeoflittleornovalue.Patientswith
extrapulmonarytuberculosisorsmear-negativetuberculosis
constituteaminimalhazardfortransmissionofinfection
(b)SOURCEOFINFECTION
:Therearetwosourcesof
intection
-
humanandbovine.(i)Humansource:Themost
Commonsourceofinfectionisthehumancasewhosesputum
ispositivefortuberclebacilliandwhohaseitherreceivedno
treatmentorhasnotbeentreatedfully.Anestimatedannual
averageof10-15personscontracttheinfectionfromone
caseotintectiouspulmonaryTB.Suchsourcescandischarge
Thebacilliintheirsputumforyears.Thetuberclebacilliina
humancaseareusuallyamixedgroup
-somemultiplyvery
rapidlyandsomeslowly.Themorerapidlyabacillarystrain
multipliesthemoresusceptibleitistothebactericidalaction
ofchemotherapeuticdrugs.Theslowmultipliersarethe
sourceofpersisterordormantbacilli;theycanremainalive
foryearswithoutcausingharmtothehost,butwhen
conditionsarefavourabletheymaystartmultiplyingagain
andcauseactivedisease.Thatis,theyaretheseedsofa
futurerelapse(20).(ii)Bovinesource:Thebovinesourceot
infectionisusuallyinfectedmilk.Thereisnodetinite
evidencethatbovinetuberculosisisaprobleminthiscountry
becauseofthepracticeofboilingmilkbeforeconsumption.
(c)COMMUNICABILITY: Patientsareinfectiveaslong
astheyremainuntreated.Etfectiveanti-microbialtreatment
reducesintectivityby90percentwithin48hours(21).
Incubationperiod
Thetimefromreceiptofinfectiontothedevelopmentof
apositivetuberculintestrangestrom3
to6weeks,and
thereafter,thedevelopmentofdiseasedependsuponthe
closenessofcontact,extentofthediseaseandsputum
positivityofthesourcecase(doseofinfection)andhost-
parasiterelationship.Thustheincubationperiodmaybe
weeks,monthsoryears.
THECONTROLOFTUBERCULOSIS
Tuberculosiscontrolmeansreductionintheprevalence
andincidence
of.diseaseinthecommunity.
Sincetuberculosisisaninfectiousdisease,thebasic
principlesofpreventionandcontrolarethesameasforany
otherintectiousdisease.Thecontrolmeasuresconsistofa
curativecomponentnamelycasetindingandtreatment:
andapreventivecomponent
-namelyBCGvaccination.
Thesearethetwofundamentalcomponentsofanationa
tuberculosisprogramme.Themostpowerful
weapon.
however,
isthecombinationofcase-findingandtreatment.
Hostfactors
(a)AGE :Tuberculosisaffectsallages.Developing
countriesshowasharpriseininfectionratesfromchildhood
toadolescence.InIndia,fromanaverageof2
percentinthe
0-14yearsagegroup",theintectionrateclimbstoabout
20percentatage15-24yearsagegroup.Inthedeveloped
countries,thediseaseisnowmorecommonintheelderly.
(b)SEX:Moreprevalent
inmalesthan
intemales.
(c)HEREDITYTuberculosisisnotahereditarydisease.
However,twinstudies(22)indicatethatinherited
susceptibilityisanimportantriskfactor.(d)NUTRITION:
Malnutritioniswidelybelievedtopredisposetotuberculosis.
Asmalnutritioniswidelyprevalentindevelopingworld,itdetectionofsputum-positivecases.Thisshouldbe
an
willcontinuetoaffectthedevelopmentofactivedisease,
out-comeoftreatmentandspreadofthedisease.
(e)IMMUNITY:Manhasnoinheritedimmunityagainst
tuberculosis.
Itisacquiredasaresultofnaturalinfectionor
BCGvaccination.Pastintectionwithatypicalmycobacteria
isalsocreditedwithcertainamountofnaturallyacquired
immunity.
Itisnowknownthatbothdelayedhypersensitivity
andacquiredresistancetotuberculosisarecell-mediated
responses.Inmostcases,thecellularimmunityproves
adequatetolimitfurthermultiplicationandspreadofbacilli.
Case-finding
a.THECASE
Thefirststepinatuberculosiscontrolprogrammeiseary
intensive,on-goingprogramme
b.PASSIVECASEFINDING
Anoverwhelmingmajorityofpatients
ofpulmonary
uoercuiosIshaveoneormoreofthesymptomsreterable
o
chest,suchaspersistentcoughandfever,andmanyortue
(over60percent)seekmedicaladviceontheiro
initiative.Thechestsymptomsoftendevelopearly,e
oerorethediseasehasgoneontoanadvancedstage.Ini
themostfertilegroupforcase-finding.
Socialfactors
c.INTENSIFIEDTBCASEFINDING(23)
Intensifiedcasesfindingactivity(ICF)isbasicaly
providerinitiatedactivitywiththeprimaryobjectveod
detectingTBcasesearlybyactivecasefindingintarwn
groupsandtoinitiatetreatmentpromptly.Itcan
haut
Tuberculosisisasocialdiseasewithmedicalaspects.It
hasalsobeendescribedasabarometerofsocialwelfare.
Thesocialfactorsincludemanynon-medicaltactorssuchas
poorqualityofIife,pooThousing,andovercrowding,
populationexploS1on,undernutrition,smoking,alcohol
abuse,lackofeducation,largefamilies,earlymarriages,
lackofawarenessofcausesofillness,etc.Allthesefactors
arëinterrelatedandcontributetotheoccurrenceandspread
oftuberculosis.Infact,tuberculosisbegantodeclineinthe
Ted
withou
symptomsorsignsofTBandalsopeoplewhodo
o
eek
peoplewhoanywayhavesoughthealthcarewitno
care.Increasedcoveragecanbeachievedbyfocusnons
clinically,sociallyandoccupationallyvulnerablepopdthat
whohavegreaterriskofTB.Itmustberemembete
lations

45. 211TUBERCULOSIS
6eroening'isadynamicprocessandtheprioritizationof
.nerable
groups,choice
ofscreeningapproachand
roeningintervalshouldberegularlyreassessedbythe
aramme.DecisionsonwhenandhowtoscreenforTB,
Phvulnerablegroupstoprioritizeandwhichscreening
tool
tousewilldependontheVulnerablegroup,thecapacity
ofthehealthsystem,andtheavailabilityofresources.
severaldecades,hashadenormousvalueinTBdiagnosis
butwithlimitedsensitivity,moresoinchildrenandPLHIV.
Undertheprogramme,twomethodsofmicroscopyare
CurrentlybeingusedZNstain-basedmicroscopyusing
conventionalmicroscopeandlightemitting.
Diodebasedfluorescentmicroscopy
(LEDFM):Culture
thoughhighlysensitiveandspecificmethodforTB
diagnosis,requires2-8weekstoyieldresultsandhencedoes
nothelpinearlydiagnosis.However,culture
isusedfor
follow-upofpatientsondrugresistantTBtreatmenttodetect
earlyrecurrence.Inaddition,itisalsousedforlongterm
follow-upforDSTBpatients,toensurerelapsefreecure.
LiquidculturesystemMycobacteriagrowthindicator
tubesystem(MGIT-B)isanautomatedculturesystemthat
detectsthegrowthofmycobacteria.Thecultureresults
areusuallyavailableupto42days.DSTresultsareavailable
14-26daysaftertheculturesturnpositive.
Screeningstrategies
1.Communityscreeningcanbedoneby
Invitingpeopletoattendscreeningatamobilefacilityor
a
fixedfacility.Invitationsmaytargetspecificallypeople
withinagivenvulnerablegroup,those
whohavehadrecentclosecontactwithsomeonewho
hasTBandpeoplewithsymptomsofTB.
Goingdoor-to-doortoscreenhouseholds.
2
Institutionalscreening
Inhealthcarefacilities:Systematicallyperformactive
screeningofvulnerableindividualsattendinghospitals
andotherhealthcareinstitution
Incongregatesettings:Systematicallyperformactive
screeningofvulnerableindividualsinshelters,oldage
homes,refugeecamps,correctionalfacilitiesand
otherspecificlocationssuchasworkplaces.
Molecular
assaysPolymerase-chain-reaction(PCR)
basedtechnologiesusingvariousmodificationsareusedfor
detectingthepresenceofputativeresistancegenes(rpoBfor
ritampicin,katGandinhAforIsoniazidetc.).
Sputumexamination:Sputumsmearexaminationby
directmicroscopyisnowconsideredthemethodofchoice.
Thereliability,cheapnessandeaseofdirectmicroscopic
examinationhasmadeitnumberonecase-tindingmethod
allovertheworld.Itenablesustodiscoverthe
Recommendationsonatriskorvulnerablegroupsto
epidemiologicallymostimportantcasesofpulmonary
tuberculosis,i.e.,thoseexcretingtuberclebacilliintheir
sputum.Thisisthegroupwhichcontributesmostofthenew
casestothe"poolofintectioneveryyear.
bescreened
Avulnerablegroupisanygroupofpeopleinwhichthe
prevalenceorincidenceofTBissignificantlyhigherthanin
thegeneralpopulation.Therecommendedvulnerable
groupstobeconsideredforintensifiedcasefindingare
discussedindetailonpage234.
Collectionofsputumsamples
Apulmonarytuberculosissuspectshouldsubmittwo
sputumsamplesformicroscopy.Thechancesoffinding
TBbacilliaregreaterwithtwosamplesthanwithone
sample.Secretionsbuildupintheairwaysovernight.Soan
earlymorningsputumsampleismorelikelytocontainTB
bacillithanonetakenlaterintheday.Itmaybedifficultfor
anout-patienttoprovidetwoearlymorningsputum
amples.Thereforeinpracticeanout-patientusually
providessputumsamplesasfollows:
d.CASE-FINDINGTOOLS
ToolsformicrobiologicalconfirmationofTBare(24)
1
SputumSmearMicroscopy(forAFB)
Zeihl-Neelsenstaining
Fluorescencestaining
2Culture:
Solid(LowensteinJensen)media
-AutomatedLiquidculturesystemse.g.BACTECMGIT
960,BacTAlertorVersatreketc.
day1sample
1
Patientprovidesan"on-the-spot"sample
undersupervisionwhenpresentingtothe
healthfacility.Givethepatientasputum
containertotakehomeforanearlymorning3.DrugSensitivityTesting
-Modifiedproportionatesensitivitytesting(PST)for
MGIT960system
samplethefollowingmorning
day2sample2Patientbringsanearlymorningsample.
Economicvariantofproportionsensitivitytesting
(1%)usingLJmedium
4
Rapidmoleculardiagnostictests:
Lineprobeassay(LPA)forMTBcomplexand
detectionofRIF&INHresistance
(FLLPA),andFQ
and
SLIresistance(SLLPA)
Nucleicacid
amplificationtest
(NAAT)(CBNAAT
truenat)
Ifthepatientiscomingfromalongdistanceorthereis
likelihoodthatthepatientmaydefaulttogiveasecond
sample,2spotspecimensarecollectedwithagapofone
hour(25)
Ziehl-Neelsenacid-faststain
Thissimplestaindetectsacidfastbacilli.Theprocedureis
asfollows:
OupportivetoolsfortheclinicaldiagnosisofTB
ChestX-rayandother
radiologicaltests
dberculinskintest(TST),Interferongammarelease
assay(IGRA)andotherbloodtests,
histopathologyand
othertissue-basedtests.
1.Fixthesmearontheslidebypassingtheslidewiththe
smearupaboutthreetimesslowlythroughaflame.It
canalsobedonebycoveringthesmearwithalcoholand
lettingthisevaporate.
mot
S microscopybeingthemostcommonlyused
od
tormicrobiologicaldiagnosisofTBforthelast
2.Coverwithcarbolfuchsin,steamgentlyfor5minutes
overdirectflame(orfor20minutesoverawaterbath).
Donotpermitslidetoboilordryout.

46. long
before
smear
microscopy),
processing
(faultysans
mearpreparation
e
npling
12
EPIDEMIOLOGYOF
COMMUNICABIL1EDISEAS
staining),or
interpreting
sputum
smears
(inadeauat.nd
smear
administrativeerrors
time
of
sputumfor
smearorfaulty
sm
Decolourizein3.0percent
acid-alcohol(95per
cent
ethanoland3.0percent
hydrochloricacid)untilonly
a
faintpinkcolourremains.
Washwithdeionizedwater.
spent
examining
smearorinadequate
attentionto
of
because
examination),or
(misidentificationofpatient,
incorrectlabellingofsample
Washwithwater.
mistakesin
documentation).
Counterstainfor
1minutewithLoeffler'smethyleneblue.
Washwithdeionizedwaterandletitdry.
Fluorescence
microscopyismainiyusedinindustralized
countries.
Itisperformedwithauraminestain.Theadvantar.
ofFAmicroscopyisfromthespeedof
examination.The d
ofviewis5-10timesbigger.Scanningofonelengthofmear
willrequireonly
1--2minutes
Fluorescence
nicroscopy
Slidereporting
(26)
Thenumberofbacilliseeninasmearrellectsdisease
everityandpatient
infectivity.Therefore,itisimportant
foo
ecordthenumberofbacilliseenoneachsmear.Thetable
elowshowsthestandardmethodofreportingusing1000
X
magnification.
Light-emlttingdiodefluorescence
microscopy(LEDs)
LEDsprovideamuchlessexpensivelightsourcefor
fluorescencemicroscopy.InarecentWHOevaluation,the
diagnostic
accuracyofLEDmicroscopywasfoundtobe
comparabletothatofconventionalfluorescencemicroscopy
andsuperiortothatofconventional
Ziehl-Neelsen
microscopy.
Itistheretore
recommendedthatLED
microscopybephasedinasanalternative
toconventional
Z-Nlightmicroscopyinbothhighandlow-volume
laboratories(27).
Resultreported
Numberofbacilli
0
No AFBper100oilimmersionfields
Scanty(ornumber
AFBseen)
1-9 AFBper100oilimmersionfields
10-99
AFBper100oilimmersionfieldsint(1+)
1-10AFBperoilimmersionfield
>10 AFBperoilimmersionfield +++(3+)
(2+)
Laboratorytechniciansshouldexamineboththesputum
samplesfromeachTBsuspect.Theymustrecordtheresult
ofeachsputumsamplewiththelaboratoryreference
numberinthelaboratoryregisterandonthesputumrequest
form.Resultsasindicatedabovearemadeavailabletothe
clinicianwhocanthencategorizethepatient.
Itisadvised
thatthesmearexaminedbyonemicroscopistshouldnot
exceed20perdayasvisualfatigueleadstoadeterioration
ofreadingquality(27).Onepositivespecimenoutofthe
twoisenoughtodeclareapatientassmearpositiveTB.
Sputumsmearmicroscopyfortuberclebacilliispositive
whenthereareatleast10,000organismspresentpermlof
sputum.ThesputumsmearpositivityrateinTB/HIVpatient
dependsonthedegreeofimmunocompromise.Ifthedegree
ofimmunocompromiseismild,thelikelihoodofpositive
sputumsmearissimilartoHIVnegativepatient.If
immunocompromiseissevere,thelikelihoodofpositive
sputumsmear
inflammationinlungs(26).
Rapiddiagnostictoolsinclude
TheCB-NAATsystemdetectsDNAsequences,specific
forMycobacteriumtuberculosiscomplexandrifampicin
resistancebypolymerasechainreaction.
Itconcentrates
mycobacteriumtuberculosisbacillifromsputumsamples,
isolatesgenomicmaterialfromthecapturedbacteriaby
sonicationandsubsequentlyamplifiesthegenomicDNAby
PCR.Theprocessidentifiesclinicallyrelevant,rifampicin
resistanceinducingmutationsintheRNApolymerasebeta
(rpoB)geneintheMycobacteriumtuberculosisgenomeina
realtimeformatusingfluorescentprobescalledmolecular
beacons.Resultsareobtainedfromunprocessedsputum
samplesin90minutes.
LineProbeAssay(LPA)
:
LineProbeAssaysdetectDNAsequencesspecitic
tor
Mycobacteriumtuberculosiscomplexaswellasmutations
conterringresistance.Sputumsamplesaredecontaminated
andthe
isdecreasedbecauseofdecreased
concentrateddepositsubjected
smear
o
microscopy.DNAisextractedfromallsmearpositive
samplesandsubjectedtoPCR:;whileallsmearnegative
samplesareinoculatedinliquidcultureandLPAperformed
usingthecultureisolateobtainedupongrowtno
Mycobacteria.ThePCRamplifiedproductsarerevers
hybridizedonnitrocellulosestripscontainingprobesspecin
fordetectionofM.TBandmutationsassociatedwithdrug
resistance.FirstlineLPAdetectsresistancetoRifampicin
(rpoB)andIsoniazid(katG,inhA),whilesecondlineL
detectsiluoroquinoloneclassresistance(gyrA,gyrB)an
secondlineinjectableclassresistance(rrs,eis).
False-positiveresultsofsputumsmear
microscopy
Afalse-positiveresultmeansthatthesputumsmearresult
ispositiveeventhoughthepatientdoesnotreallyhave
sputumsmear-positivePTB.Thismayarisebecauseofthe
following:redstainretainedbyscratchesontheslide;
accidentaltransferofAFBsfromapositiveslidetoa
negativeone;contaminationoftheslideorsmearby
environmentalmycobacteria;presenceofvariousparticles
thatareacid-fast(e.g.foodparticles,precipitates,other
microorganisms).
NucleicAcidAmplificationTest(NAAT)providesaccura
andrapiddiagnosisofTBbydetectingMycobacteriu
tuberculosis(M.tuberculosis)
andRifampicin(Rif)resistan
conferringmutations,insputumspecimenaswel
specimenfrom
False-negativeresultsofsputumsmear
microscopy
Afalse-negativeresultmeansthatthesputumsmear
resultisnegatíveeventhoughthepatientreallydoeshave
sputumsmear-positivePTB.Thismayarisebecauseof
problemsincollecting(patientprovidesinadequatesample,
inappropriatespufumcontajnerusedorsputumstoredtoo
as
extra-pulmonary Under
the
programme,
itsuseisrecommendedfordiagnosisot
LD
sites.
TE
inpresumptiveDR-TB
patientsandTBpreferentiallyin
populationsuchaschildren,PLHIV,Extra-pulmonary
TB
andinsmearnegativeTBasperthediagnosticalgoritn

47. 1EREKISIG 213
Radiography
ChestX-raysareiselullorthediagnosisofsmea
negativeplulmonaty5
and
T13inchildren.It
isnot
tinelyindicatedin
simear-postivecases.X-taysare
inuabletoolsforthediagnosisofpleuralandpericardial
effusion,especiallyinearlystagesofthediseasewhen
clinicalsignsareminimal.ftisessentialinthediagnosisof
niliaryTB.Theotherindicationsarefrequentorsevere
haemoptysistoexcludebronchiectasisoraspergillomaand
inpatientsneedingspeciflictreatmentforpneumothorax.
Induration
CGroup
Si2e
5mm 1.HIV-posítivepersons
2.Recentcontactsofindividuaiswith
tuberculosis.
active
3.Personswithfibroticchangesonchestfilms
5uggestiveofpriortuberculosis.
4.Patientswithorgantransplantsandather
immunosuppressedpatients(rereivingthe
equivalentof>15mgdofprednisonefor
Imanthor
more)
1.Recentimmigrants
(
<5years)fromcountrieswitha
highprevalenceoftuberculosis(eg.Asia,Africa.
LatinAmerica.
2.HIV-negativeinjectiondrugusers.
3.Mycobacteriologylaboratorypersonnel.
4.Residentsofandemployeesinthefoliowinghigh-
riskcongregatesettings:correctionalinstitutions
nursinghomesandotherlong-termfacilitiesforthe
elderly:hospitalsandotherhealthcarefacilities
residentialfacilitiesforAIDSpatients;andhomeless
shelters.
TUBERCULINTEST
210mmm
ThetuberculintestwasdiscoveredbyVonPirquetin
1907.Apositivereactiontothetestisgenerallyacceptedas
evidenceofpastorpresentinfectionbyM.tuberculosis.The
tuberculintestistheonlymeansofestimatingthe
prevalenceofinfectioninapopulation
Tuberculin:Onlytwotuberculinshavebeenaccepted
asstandardtuberculinbyWH0,i.e.,purifiedprotein
derivative-S(PPD-S)andPPD-RT23.PPDisstandardized
intermsofitsbiologicalreactivityastuberculinunits(TU).
Astandard5tuberculinunit(5TU)doseofPPD-Sisdefined
asdelayedskinactivitycontainedina0.1ug/0.1mldoseof
PPD-S.1TUofPPD-RT23isequivalentto5TUof
PPD-S.InIndiaPPD-RT23withTween80isused.Tween
80isadetergentaddedtotuberculintopreventtheir
adsorptiononglassorplasticsurface.Useoftuberculin
strengthof1TUisrecommendedforstandardMantouxtest
inIndia.
5.Personswiththefollowingmedicalconditionsthat
increasetheriskoftuberculosis:gastrectomy.2
10%
belowidealbodyweight.jejunoilealbypass,diabetes
mellitus,silicosis.advancedchronickidneydisease.
somehematologicdisorders.íeg.leukemias
lymphomas)andotherspeciticmalignancieseg.
carcinomaoftheheadorneckandlung.
6.Children<4yearsofageorinfarnts,childrenand
adolescentsexposedtoadultsathighrisk.
215mm 1.Personswithnoriskfactorsfortuberculosis.
MANTOUXTEST:TheMantouxtestiscarriedout
injecting
1TUofPPDin0.1mlintradermallyontheflexor
surfaceoftheleftforearm,mid-waybetweenelbowand
wrist.Theinjectionshouldbemadewithatuberculin
syringe,withtheneedlebevelfacingupward.Whenplaced
correctly,injectionshouldproduceapalewhealoftheskin,
6to10mmindiameter.Theresultofthetestisreadafter
48-96hoursbut72hours(3rdda
A
negativetuberculintestmustalsobeinterpretedwith
caution.Formanyyears,ithasbeenassumedthata
negativetestconstitutedstrongevidenceagainstthe
presenceofactivetuberculousdiseaseinthemajorityof
cases.Ithasbeenshownthatinthemajorityofpatientswith
tuberculosis,thecellularimmuneresponsemaybe
depressed.Itmeansanegativetuberculintestcannotbe
reliedupon
hypersensitivitytotuberculincanaisobelostinvarious
statesofimmunesuppression,e.g..malignancy,Hodgkin's
disease,HIVinfection,malnutrition,severebacterial
infection(includingTBitseli),viralinfections(e.g.measles,
chickenpox,glandularfever),recenttive-virusvaccination
(e.g.measles),immunosuppresivedrugs(e.g.steroids)and
incorrectinjectionofPPD.Therefore,toogreatadiagnostic
significanceshouldnotbeplacedonanegativetuberculin
test(18).
istheal. toexcludetuberculosis.Thedermal
Tuberculinreactionconsistsoferythemaandinduration.
Sinceerythemaissometimesdifficulttomeasure,induration
aloneismeasured(horizontaltransversediameterof
indurationinmillimetres,usingatransparentplasticruleror
callipers.Reactionsexceeding10mmareconsidered
Ositive.Thoselessthan6mmareconsidered"negative".
hosebetween6and9mmareconsidered"doubtful",i.e.,
nereactionmaybeduetoM.tuberculosisoratypical
ncobacteria.Ifthereisnoinduration,theresultshouldbe
recorded
as0'.
Two-steptesting
t
hasbeenfurtherobservedthatstrongreactors(i.e.,
uoseshowing20mmormoreinduration)havegreater
ances
ofdevelopingtuberculosisthanthoseshowing
ominduration.Thosewithlessthan5mminduration
aemoreriskofdevelopingtuberculosisthanthosewith
minduration.Studiesindicatethat92percentof
casesoccur
inpersonswhoarealreadytuberculin
eactors(28).Thesefindingsillustratetheprognostic
significance
ofthetest
SomepeoplewhowerepreviouslyinfectedwithTBmay
haveanegativereactionwhentestedyearsafterinfection,as
theimmunesystemresponsemaygraduallywane.Thisinitial
skintest,thoughnegative,maystimulate(boost)thebody's
abilitytoreacttotuberculinintuturetests.Thus,apositive
reactiontoasubsequenttestmaybemisinterpretedasanew
infection,wheninfactitistheresultoftheboostedreaction
toanoldinfection.GivingasecondTSTatteraninitial
negativeTSTreactioniscalledatwo-steptesting.Useoftwo-
steptestingisrecommendedtorinitialskintestingofadults
whowillberetestedperiodically(e.g,healthcareworkers).
assificationofpositivetuberculinskintest
Teaction
(29)
transu
Atul
uinskintestreactionisconsideredpositive
ifthe
ediameteroftheinduratedareareachesthesize
COneorthespecificgroup.Allotherreactionsare
Thefirsttestisread48-72hoursafterinjection.
-Ifthefirsttestispositive,considerthepersoninfected.
lfthefirsttestisnegative,giveasecondtestoneto
threeweeksafterthefirstinjection.
:
Considera
negative.Theclassificaitonisasfollows:

48. 2 EPIDEMIoLOGYOFCOMMUNICABLE DISEASES
eliminationofboththefastandslowly
iplying
(includingthepersisters)fromthepatient'sbody.ThDacil
ofchemotherapyarejudgednotbytheanatomic
etfects
lesions,butmainlybytheeliminationofbacilirngof
patient'ssputum.Chemotherapyshouldbeeasilum
the
Thesecondtestisread48-72hoursafterinjection.
-Itthesecondtestispositive,considertheperson
previouslyinfected.
-I1
thesecondtestisnegative,considertheperson
uninfected.
freeofchargetoeverypatientdetected.
Itshould
b
adequate,appropriateandappliedtothe
entire
n De
of
infectorsinthecommunity.
atientcompliance
iscritically
,Thevalidityoftuberculintest,likeallmedicaltests,is
subjecttovariability.Itislimitedbylackofspecificity.Apart
romerrorsassociatedwiththemodeofadministration,
readingofresultsandthetestmaterialused,thereareother
actorssuchascross-reactionsduetosensitizationbyother
mycobacteria,whichshouldbetakenintoaccount.In
countrieswithahighcoverageofBCG,whichalsoproduces
Tuberculinhypersensitivity,tuberculintesthaslost
its
sensitivityasanindicatorofthe"true"prevalenceof
intectionThetrueprevalenceratesofinfectionmaybe
exaggeratedbyinfectionwithatypicalmycobacteriaaswell
astheboostingeffect"ofaseconddoseoftuberculin
producingalargerreactionthanthefirst(30).
Itisoftenassumedthatdelayedhypersensitivityas
measuredbytuberculintestingisacorrelateofthe
protectiveimmuneresponse.Butevidenceindicatesthat
thishypersensitivityisirrelevanttotheabilityofthehostto
combatthedisease.Despitetheselimitations,thetuberculin
testcontinuestobetheonlytooltormeasuringthe
prevalenceoftuberculousinfectioninacommunity.Ithas
beenaptlysaidthattuberculintest"mustbeapproached
withrespect,administeredwithcare,readwithdeliberation
andinterpretedwithsentientdiscrimination.
Tepool
important;thepatientmusttakethecorrect
correctdosagetorthecorrectlengthoftime.Ineothe
treatmentputsthepatientat
risk
of
relapseand
developmentofbacterialresistanceand,importanth
communityatriskofinfectionwithresistantorganismsne
he
Anti-tuberculosisdrugs
Therearenowtwelveorthirteendrugsactive
against
M.tuberculosis,ofwhich,sixareconsideredtobeessential
Anantituberculardrugshouldsatisfythefollowing
riteria:
(a)highlyeffective(6)freefromside-effects(c)easu
administer,and(d)reasonablycheap.The
currently
Used
drugsmaybeclassifiedintotwogroups:bactericidal
and
bacteriostatic.Thebactericidaldrugskillthebacilliin
ivo.
Thebacteriostaticdrugsinhibitthemultiplicationofthebacilk
andleadtotheirdestructionbytheimmunemechanismofthe
host.Abriefreviewofthesedrugsisgivenbelow.
to
THEFIRST-LINEDRUGS
BACTERICIDALDRUG3s
Rifampicin(RMP)
RMPisapowerfulbactericidaldrug.Itisabetter
sterilizingagentthanINH.Itpermeatesalltissuemembranes
includingtheblood-brainandplacentalbarriers.Itisequally
effectiveagainstintracellularaswellasextracellularbacili.It
TBInterferongammareleaseassays(1GRAs)
TheInterferonGammaReleaseAssays(IGRAs)areanew
typeofmoreaccuratetestforTB.1GRAsarebloodteststhat
measureaperson'simmuneresponsetothebacteriathat
causeTB.Theimmunesystemproducessomespecial
moleculescalledcytokines.TheseTBtestsworkbydetectingistheonlybactericidaldrugactiveagainstthe"persisters"or
acytokinecalledtheinterterongammacytokine.Inpractice
youcarryoutoneoftheseTBtestsbytakingabloodsample
andmixingitwithspecialsubstancestoidentifyifthedistinctadvantageoverINH.Rifampicinisofspecialvalue
cytokineispresent.TwoIGRAsthathavebeenapprovedand
arecommerciallyavailable,aretheQuantiFERON®TBGold itcancureevenextensivetuberculosis,inabout
9months.
test,andtheT-SPOT®TBtest.TheadvantagesofanIGRA
TBtestincludesthefactthatitonlyrequiresasinglepatient
visittocarryouttheTBtest.Resultscanbeavailablewithin
24hours,andpriorBCGvaccinationdoesnotcauseafalse
positiveresult.Disadvantagesincludethefactthattheblood
samplemustbeprocessedfairlyquickly,laboratoryfacilities
arerequired,andthetestisonlyforlatentTB.Itisalso
thoughtthattheIGRAsmaynotbeasaccurateinpeoplewho
haveHIV.Inlowprevalenceresource
richsettings,IGRAsare
beginningtobeusedinplaceoftheTBskintest(31).
dormantbacilliwhicharefoundinthesolidcaseouslesions,
allotherdrugsbeinginactive(32).Inthisregard,ithasa
whenthebacilliresistsotherdrugs.IncombinationwithINH,
RMPisusedonlyasoraldrug.Itissowellabsorbedthat
thereislittleneedforparenteraladministration.
Thedose
shouldbetakenatleastonehourbeforeor2hoursater
foodbecauseabsorptionisreducedbyfood.Itisnever
uised
aloneforthetreatmentoftuberculosis,butalwaysusedn
combinationwithINHoranotherdrug.
Case-findingshouldnotbeanendinitself.Itisoflittle
valueasacontrolmeasureunlessfollowedbychemotherapy.
Resourcesandeffortsshouldbedirectedtowardsprimary
healthcare,ratherthanirrationalcasefinding
Pleaserefertopage217forthe
flowchartfordiagnosis
oftuberculosisinadults,asfollowedbyNTEP.
Manypatientsdevelopnauseaatthestartoftreatmen
butthispassesoff.Thetoxiceffectsincludehepatotoxicu
gastritis,influenza-likeillness,purpura,thrombocgtope
andnephrotoxicity.Thepatientshouldbetoldthatthe
aruy
willturntheurinered;thiscanbeusedastestofcomplan
PASdelaysitsabsorption;henceconcii
administrationwithPASshouldbeavoided.
IfRMF,
stoppedtorsomereason,itshouldnotberestartedwi
3weekstoavoidhypersensitivity.
INH
Chemotherapy
Thedevelopmentofeffectivetreatmentfortuberculosis
hasbeenoneofthemostsignificantadvancesduringthis
century.Withtheevolutionofcontrolledtrials(seepage92),
thechemotherapyoftuberculosisisnowmorerationally
based,thaninthetreatmentofotherinfectiousdiseases.
Chemotherapyis
indicatedineverycaseofactive
tuberculosis.Theobjectiveoftreatmentiscurethatis,the
INHranksamongthemostpowerfuldrugsell
treatmentoftuberculosis.Itcaneasilypenetrateand
membrane,andisthusactiveagainstinrd
ADidly
extracellularbacilli.Itsactionismostmarkedonlies
multiplyingbacilli.ItislessactiveagainstslowTmE1S
INHgetswidelydistributedinthebodyincluains
cos
easeofadministration,freedomfromtoxicityanu
makesitanidealcomponentforanydrugregime

49. ethambutol)foraperiod
oft2months,
followedby2drOr
rifampicin
or
216
EPIDEMIOLOGYOF
COMMUNICABIE
DISEASESs
pyrazinamide,
supplemented
byeither
streptomun
2drugs
in
significantdrug
side-effects.
However,afewpatientsdo
developmajorreactionsanditisimportanttomonitor
clinicallyallthepatients.
Apatientwhodevelopsoneofthe
tolowingreactions
mustneverreceivethatdrugagain(32)1
(INHplus
the
continuation
phase,
tment
thioacetazone)givendailyor
intermittently.ThetreatOr
by
mustbe
fullysupervisedandmonitored
mainl
bacteriological
examination.
Drug
responsible
DIRECTLY
OBSERVED
TREATMENT,SHORT
COURSE
(DOTS)
CHEMOTHERAPY
Reaction
Thioacetazone
a.Severerash.
agranulocytosis
b.Hearinglossordisturbedbalance
CVisual
disturbance(poorvisionand
colourperception)
d.Renalfailure,shockorthrombocytopenia
Streptomycin
Ethambutol DOTSisastrategytoensurecurebyprovidingthemost
effectivemedicineandconfirmingthatitistaken.
Itis
the
onlystrategywhichhasbeendocumented
tobeeffective
worldwideona
programmebasis,
InDOl5,
duringthe
intensivephaseoftreatmentahealthworkerorothertrained
personwatchesasthepatientswallowsthedruginhis
presence.Duringcontinuationphase,
thepatientisissued
medicineforoneweekinamultiblistercombipack,ofwhich
thefirstdoseisswallowedbythepatient
inthepresenceof
healthworkerortrainedperson.heconsumption
of
medicineinthecontinuationphaseiSalsochecked
byreturn
ofemptymultiblistercombipack,whenthepatientcomesto
collectmedicineforthenextweek.Thedrugsareprovided
inpatient-wiseboxeswithsufficientshelf-life.
Rifampicin
Pyrazinamide
e.Hepatitis
Fwo-phasechemotherapy
Itiswellrecognizedthattherearetwophasesintheeffective
treatmentoftuberculosis:
(i)thefirstisashort,aggressiveor
intensephase,earlyinthecourseoftreatment,lasting
1-3months.Duringthisintensivephase,threeormoredrugs
arecombinedtokilloffasmanybacilliaspossible.Themore
rapidlythebacilliarekilledinitially,thelesslikelyare
"persisterstoemerge.Theriskofrelapse
isalsolessened.
(ii)thesecondor"continuationphaseisaimedatsterilizingthe
smallernumberofdormantorpersistingbacilli.Inthestandard
anti-tuberculoustherapy,thedurationoftreatmentwasnotless
than18monthstoachievecompletesterilizationofthebacilli.
Withtheintroductionofrifampicinandpyrazinamide,this
periodisnowsuccessfullyreducedto6-9months.
INTRODUCTIONOFDAILYDOSE
REGIMENINNTEP
Thetechnicalandoperationalguidelines-2016forTB
controlinIndia,definemajorgroupsofTBpatientswhoare
offeredstandardtreatmentregimen.Patient'sclassificationis
basedondrugsusceptibilityresultasdrug-sensitive
TB:and
mono,poly,RR,multiandextensivelydrugresistantTB.For
drug-sensitiveTBpatients,thethriceweeklyintermittent
TB
regimenusedsinceinceptionoftheprogrammehasbeen
switchedtoadailyfixeddosecombinationregimen
(34)
DOMICILIARYTREATMENT
Theself-administrationofdrugs(generallyoraldrugs)by
thepatientsthemselveswithoutrecoursetohospitalizationis
calleddomiciliaryorambulatorytreatment.Theclassical
controlledclinicaltrials(35)carriedoutattheTuberculosis
ChemotherapyCentre,Chennaishowedthattheincidenceof
tuberculosiswasnogreaterinthecontactsofpatientstreated
athomethaninthecontactsofpatientstreatedinsanatoria.
Itisnowuniversallyacceptedthatwithgoodchemotherapy,
hospitaltreatmenthasnoadvantageoverdomiciliary
treatment,anddomiciliarytreatmentistobepreferred
becauseinthelongrun,itissomuchcheaperthanhospital
treatment,andthatitcanbemanagedbytheprimaryhealth
caresystemandthegeneralhealthservicesofthecountry.It
maybementionedthatitwasthisstudy,theclassicalChennai
Study,thatpromptedaradicaldeparturefromthetraditional
sanatoriumtoambulatoryordomiciliarytreatment.
1.MANAGEMENT OFDRUGSENSITIVE
TUBERCULOSIS(2019)
Earlyidentificationofpeoplewithahighprobabilityof
havingactiveTB(presumptiveTB)isthemostimportant
activityofthecasefindingstrategy.Screeninganddiagnosing
patientswithappropriatetestsandstrategieswilllargely
determinetheresponsetoappropriatetreatment.Passive
case
findingalonecanleadtomissedcasesordelayeddiagnosis.
AllpresumptiveTBwillundergosputum
smear
examination(ZN/LEDFM).Twospecimensarecollected
(spot-earlymorningorspot-spot).Ifthefirstsmearispositive
andthepatientisnotattheriskofdrugresistant
TB,hewi
becategorizedasmicroscopicallyconfirmedTB(sensitivi
Statusnotknown).Ifthefirstsmearisnegative,CXRmay
consideredandifreportedassuggestiveof
TB,the2n
samplewillbesubjectedtosmearandCBNAR
simultaneously.BasedonCBNAATresults,patientwillbe
categorizedasmicrobiologicallyconfirmeddrugsensitive
ForNTEPendorsedTBdiagnostics,Fig.2shows
the
diagnosticalgorithmforpulmonarytuberculosis.
SHORT-cOURSECHEMOTHERAPY
Foralongtime,thestandarddurationoftuberculosis
chemotherapywas18months.In1972,WallaceFoxandhis
colleaguesfromtheBritishMedicalResearchCouncil
showedthattheadditionofritampicinorofpyrazinamideto
regimenscontainingINHmadeitpossibletoreducethe
durationoftreatment
Thereareanumberofadvantagesofshort-course
chemotherapy,viz.rapidbacteriologicalconversion,lower
failureratesandareductioninthefrequencyofemergence
ofdrug-resistantbacilli.Patientcomplianceisimproved,
theybecomenon-infectiousearlier.Thedisadvantageisthat
thehighcostofshort-termchemotherapymilitatesagainst
itswideruseindevelopingcountries.
Pre-treatmentcounsellingandevaluation
Thepatientandhis/herfamilymembersshoula
be
cOunselledaboutthetypeofdisease,modeofspreau
the
treatment
durationanddosageschedule,common
arular
sideTherearenowanumberofshort-courseregimensof
6monthsdurationthatarehighlyeffective,oflowtoxicity,
andwell-tolerated.Thesepotentregimensarebasedonan
initialintensivephasewith4drugs(INH,rifampicinand
effectsandmethodstopreventthem,importanceOaingtreatmentandconsequencesofirregulartreatment,screan
ofco-morbiditieslikediabetes,líverorrenaldiseasefoneurologicaldisorderetc.Itisalsoimportantto
forlook

50. TUBERCULOSIS 217
PresumptiveTBpatient
Smearexamination
CXR
Clinical
Smearpositive
andCXR
suggestiveofTB
Smearpositive,
butCXRnot
Smearnegative
butCXR
Smearnegativeornotavailable&
CXRnotsuggestiveofTBobr
notavailable
suspicion
highsuggestiveofTB SuggestiveofTB
CBNAAT
PMDTcriteria,high
MDRsettings
ConsiderMTBnotdetectedorCBNAAT
resultnotavailable
MTBdetected
Clinically
diagnosedTB
alternate
diagnosis
andrefer
tospecialist
Alternate
Referto
managementof
Rifresistance
RifsensitiveRifindeterminateRifresistant
diagnosis
Microbiologically
confirmedTB
RepeatCBNAAT
on2ndsample
Indeterminateon2ndsample,collect
freshsampleforLiquidCulture/LPA
*AllpresumptiveTBcasesshouldbeofferedHIV
counsellingandtesting,howeverdiagnosticwork
upforTBmustnotbedelayed.
FIG.2
DiagnosticalgorithmforpulmonaryTB
rce:(23)
andactivitiesrelatingtothedetection,assessment.
understandingandpreventionofadverseeffectsoranyother
drug-relatedproblem".Itisfundamentalactivitytoinform
themanagementofpatientsafetymeasurementinhealth
care.Itisapublichealthsurveillanceactivity.Priorityisgiven
toestablishpharmacovigilanceatdrugresistanceTBcentres.
stanceabuseespeciallytobacco(inanyform)andalcohol.
io-economicstatusofthepatientmaybeassessedtolink
v/herwithappropriatetreatmentsupportschemes.HIV
ingshouldbedoneinallthecasesofTB.Thisisimportant
ensurethatallHIVpositivecasesofTBreceiveanti-
roviraltherapyandco-trimoxazolepreventivetherapy(23).
Sincethedrugsusedinthetreatmentoftuberculosisare
Owntoproduceadverseeffects,aproperpre-treatment
aluationisessentialtoidentifypatientswhoareat
creasedriskofdevelopingsuchadverseeffects.Thepre
-
2atmentevaluationincludesthefollowing
:
Detailedhistory(includingmentalillness,seizure,drug
andalcoholabuseetc).
Weightandheight.
Complete
bloodcount.
5loodsugartoscreenfor.diabetesmellitus.
Liverfunctiontest.
00d
ureaandcreatininetoassesskidneyfunction.
neexamineroutineandmicroscopic.
Recommendeddailydoseregimenfordrug
sensitiveTB(2019)
Theprincipleoftreatmentfortuberculosis(otherthan
confirmeddrugresistantformsofTB)withdailyregimenis
toadministerdailytixeddosecombinationsoffirst-line
anti-tuberculosisdrugsinappropriateweightbands.
Fixeddosecombinations(FDCs)
Fixeddosecombinations(FDCs)refertoproducts
containingtwoormoreactiveingredientsinfixeddoses,
usedforaparticularindication(s).
InNTEP,forAdults
-4-FDC(giveninIP)consists
ofHRZEand3-FDC(giveninCP)consistsofHRE.
Forpaediatricpatients
-
dispersible3FDCconsistsofHRZ
anddispersible2FDCconsistsofHR.
Most
patientsonfirstlinedrugscompletetheir
8.ChestX-ray.
regnancytest(forallwomen
inchildbearingagegroup)
AduantagesofFDCs
.Simpliçityof
treatment
.Increasedpatientacceptance
Fewertabletstoswallow
efectehout
anyseriousdrugsideeffects.Trivialside
nenceastato
reducedcompliancewiththetreatment,
Comm ptom-basedapproachtothemanagementofthe
Onadverseeffectshouldbeadopted
Pharm
PhatmcobigilanceinTBcontrol
programme
ance isdefinedbytheWHO
asthesCience
Prevents'concealed'irregularity

51. 218
EPIDEMIOLOGYOFCOMMUNICABLE DISEASES
Increasedhealthworkercompliance
Fewertabletstohandle,hencequickersupervisionof
DOT
Easierdrugmanagement
Reduceduseofmonotherapy
Duringtreatmentiftheweightofthepatientincreas
morethan5kgandcrossestothenextweightbandcated
thenpatientshouldbegiventhenexthigherweightban
FDCdrugs.
band
-Lowerriskofmisuseofsingledrugs
Lowerriskofemergenceofdrugresistance
Easiertoadjustdosagesbybodyweight
TreatmentofpaediatricTB
PaediatriccasesaretobetreatedunderNTEPindail.
dosagesasper6weightbandcategories.Alladolescents
upto18yearsofageandweighinglessthan39kg,are
toho
treatedusingpaediatricweightbandsandchildreneighing
morethan39kgwithadultweightbands.
Treatmentisgivenintwophases(24):
Intensivephase(IP)consistsof8
weeks(56doses)of
isoniazid(H),rifampicin(R),pyrazinamide(Z)and
ethambutol(E)givenunderdirectobservationindaily
dosagesasperweightbandcategories.
Continuationphase(CP),consistsof16weeks(112doses)
ofisoniazid,rifampicinandethambutolindailydosages.
Onlypyrazinamidewillbestoppedinthecontinuation
phase.TheCPmaybeextendedby12-24weeksincertain
formsofTBlikeCNSTB,skeletalTB,disseminatedTBetc.
basedonclinicaldecisionofthetreatingphysicianoncase
tocasebasis.Extensionbeyond12weeksshouldonlybe
onrecommendationofspecialists.
Keyproductinformation(forpaediatric)
1.DispersibleFDC,flavoured
Rifampicin75mg+Isoniazid50mg+
Pyrazinamide150mg
Rifampicin75mg+Isoniazid50mg
2.DispersibleLoosedrugs
Ethambutol100mg
Isoniazid100mg
DrugdosageforpaediatricTB(24)
Numberoftablets(dispersibleFDCs)Weight
category
Treatment Treatment
TypeofTBcase
regimeninIPregimeninCP
Intensivephase Continuationphase
4HRE HRZ E HR E
Newandpreviouslytreatedcases
(HandRsensitive/unknown)
Prefixtothedrugsstandsfornumberofmonths.
Loosedrugscouldbeusedassubstitutionsincase
off
adversedrugreactionorwithcomorbidconditions.
2HRZE
50/75/150 100 50/75 100
4-7kg
8-11kg
12-15kg
16-24kg
25-29kg
L
3+1A*3
30-39
kg2+2A* 2
AAdultFDC(HRZE
=
75/150/400/275;HRE=75/150/275).Itis
addedinhigherweightbandcategoriesi.e.>25kgasthesechildren
maybeabletoswallowtablets.
2 2
3 3
3
Steroidsasanadjunctivetherapyisusefulinpatients
withTBpericarditisandmeningealTB,withaninitialhigh
dosetapereddownwardsgraduallyover6-8weeks.
4 4 4
3+1A* 3
2
+2A 2
Drugdosagesforfirstlineanti-TBdrugs
Maximumin
children
Drugs Adults Children
10mg/kgdaily
(7-15mg/kg)
15mg/kgdaily
(10-20mg/kg)
35mg/kgdaily
(30-40mg/kg)
20mg/kgdaily15
mg/kgdaily
|
(15-25mg/kg)
20mg/kgdaily
(15-20mg/kg)(15-20
mg/kg)
5mg/kgdaily
(4to6mg/kg)
10mg/kgdaily
(8-12mg/kg)
25mg/kgdaily
(20-30mg/kg)
Changeinweightbandstobeeffectiveuponcrossing
of
weightbandsirrespectiveofthequantumofweightgain/los.
Pyridoxinemaybegivenatadosageof10mgperdayto
allchildrenreceivingINHcontainingtherapyirrespective
ot
Isoniazid 300mg
Rifampicin 600mg
Pyrazinamide 2000mg
agegroup.
Nikshayentry:Oncethetreatmentregimen
isfinalized.
allpatientsshouldbeinitiatedontreatmentafteropen
thetreatmentcardandentriesaredoneinNikshay.MO-P
shouldensurethatthetreatmentdetailsareentered
NikshaybythePHIstaff.NikshayentryshouldnotDea
separateactivity.Alleventsstartingfromnotification
l
treatmentoutcomearefromNikshayasitisintegrated
pa
ofdocumentation(24).
Ethambutol" 1500mg
(12-15mg/kg)
15mg/kgdaily
1000mg
Streptomycin
Streptomycinisadministeredonlyincertainsituations,likeTB
meningitisorifanyfirstlinedrugneedtobereplacedduetoADRas
perweightofthepatient
Ethambutolisgivenseparatelyforchildrentomonitorophthalmic
ADR Follow-upofthetreatment
Therearetwocomponentsofthefollow-up:
a.Clinicalfollowup:Itshouldbedoneatmonthlyintera
mprovementinchestsymptoms,increaseinweig
mayindicategoodprognosis.
b.Laboratoryinuestigations
shouldbedoneattheendofintensive
Dailydosescheduleforadults
(asperweightbands)(24)
Numberoftablets(FDCs)
Weight
category
ContinuationphaseHRE
putum
smear
microscop
phaseand
end
or
treatment.Anegativesputumsmearattheend
of
IP
IntensivephaseHRZE
75/150/400/275 75/150/275
25-34
kg
35-49kg
50-64kg
65-75kg
275kgL
ce
indicategoodprognosis.However,intheprescide
clinicaldeterioration,themedicalofficermaydring
dur
repeatingsputumsmearmicroscopye
continuationphase.Thiswillprovidethepatieind.
early
At
Opportunitytoundergodrugsusceptibilitytest

52. TUBERCULOSIS 219
Groupingofmedicines
recommendedforusein
longerMDR-TBregimens
completionofthetreatment,asputumsmearand/or
cultureshouldbedoneforeverypatient,ascultureismore
Specificandsensitivecomparedtosmearmicroscopyto
detectthepresenceofM.TBinbiologicalspecimens.
Longtermfollow-upattheendof6,12,18,and
24monthsshouldbedone.
Inpresenceofanyclinical
Symptomsand/orcough,sputummicroscopyand/orculture
shouldbeconsidered(23).
Medicine
Groups
&steps
Lfx
levofloxacinOR
Group
A:
Includeallthreemedicines
Mtx
moxifloxacin
bedaquiline
linezolid
clofazimine
cycloserineOR
terizidone
ethambutol
delamanid
Pyrazinamide
imipenem-cilastatin
ORmeropenem
Bdq
Lzd
Cfz
2.
MANAGEMENT OFDRUG-RESISTANT TB GroupB:
Addoneorbothmedicines
Cs
Trd
ProvidingtreatmenttodiagnosedDR-TBpatientsis
extremelyimportant.lobeginwith,onlyMDR-TBpatients
wereofferedtreatmentwithastandardsecond-lineregimen.
Later,treatmentwithstandardregimenwasofferedto
extensivelydrugresistant(XDR)TBpatientsandMDR-TB
withadditionalresistancetofluoroquinolonesorsecond-line
injectable.Procurementandsupplychainmanagementof
second-linedrugs
iScomplex,sincenostandardizedpatient-
wiseboxesaremanutacturedanddrugsdoneed
temperatureregulatedstorageandrepacking.
Since2016,newdrugslikeBedaquiline(Bdq)aremade
accessibletoDR-TBpatientsthroughexpandedaccessunder
NTEPIn2016,withthereleaseoftheRevisedTechnicaland
OperationalGuidelines,regimenstotreatotherformsof
drugresistance,suchasmonoandpolyresistancetofirst
andsecond-linedrugswerealsoincluded.
E
Group
C
Addtocompletethe
regimenandwhen
medicinesfromGroupsA
and
Bcannotbeused
Dim
Z
Ipm-Cln
Mpm
Am
amikacin
(S)
(ORstreptomycin)
EtoethionamideOR
Ptoprothionamide
p-aminosalicylicacid PAS
Source:(37,24)
Pretreatmentevaluationfordrug-resistant
patients
SincethedrugsusedforthetreatmentofDR-TBhave
significantadverseeffects,apretreatmentevaluation
is
essentialtoidentifypatientsatincreasedriskofdeveloping
suchadverseeffects.Thispretreatmentevaluationisas
follows:
GuidelinesforPMDTTB(2019)
In2019theWHOpublishedconsolidatedguidelineson
thetreatmentofdrugresistantTB.Ithassubstantially
changedtheapproachtothetreatmentofMDR/XDR-TB.
includes(24,36)
Pretreatmentevaluations
policyrecommendationsontreatmentregimensfor
isoniazidresistantTBandmultidrugandrifampicin
resistantTB(MDR/RR-TB),includinglongerandshorter
regimens;
Detailedhistory(includingscreeningformental
illness,seizuredisorder,drugalcoholabuse,etc.)
PrevioushistoryofATTtakenespeciallySLI/FQ
Weight&height
culturemonitoringofpatientsontreatment;
thetimingofantiretroviraltherapyinMDR/RR-TB
patientsinfectedwithHIV;
theuseofsurgeryforpatientsreceiving
MDR-TB
treatment;and
Thoroughclinicalexamination
Completebloodcountwithhaemoglobin&
plateletscount
BloodsugartoscreenforDiabetesMellitus
BloodureaandS.Creatininetoassessrenalfunctionoptimalmodelsofpatientsupportandcare.
Accordingtothe2019consolidatedguidelines,fullyoral
regimensshouldhavepriorityandshouldbecomean
optionformostpatients.Injectableagentsshouldnolonger
Deamongthepriorítymedicinesfordesigninglonger
MDRTB
regimens.
Urineexamination-routineandmicroscopic
9 UPT(forallwomeninthechild-bearingage)
10ChestX-ray
11 HIVcounsellingandtesting'
12Audiogram
Ifneedstobeemphasizedthattreatmentfordrugresistant
Bshouldonlybeprovidedunderthesupervisionofan
perienceddoctor.Thisincludesthechoiceofashorteror
1ongerregimen,andalsowhetherinjectabledrugsareused.
Accordingly,Indiahasmadesomechangesinits
MDTguidelines.TherevisedintegratedDR-TBdiagnostic
digorithmrecommendstestingofallTBpatientsfor
ampicinandisoniazidresistanceandallRR-TBpatientsfor
uoroguinoloneandsecondlineinjectable.Fig.3on
age220showstheintegrateddrugresistantTB
algorithm(2019)
13Liverfunctiontests"
14TSHlevelstoassessthethyroidfunction
15Mentalhealthevaluation
16Surgicalevaluation
17ECG(ifMfx,Dlm,Bdq,Ctzused)
18Serumelectrolytes-potassium,magnesium,calcium
19Serumproteins,lipase,amylase
Ophthalmologistopiniontoruleout
chorioretinitis/uveitis
20
he
medicinesrecommendedforlonger
MDR-TB
mensareclassifiedintothreegroups(A,BandC)based
ticaey,experienceofuseanddrugclassandaligned
revised
classificationasperWHOconsolidated
udelinesfortreatmentofdrugresistantTB.Thegroupsare
aslistedbelow
AllDR-TBpatientswillbeofferedreferralforHIVcounsellingand
testingatthenearestcentreiftheHIVstatusisnotknownor
HIV
test
resultisnegativewithresultsmorethan6monthsold.IfpatientisHIV
positive,refertoARTcentre(ifnotonART)
includingHBsAgatbaseline
Source:(24)

53. 220
EPIDEMIOLOGY
OFCOMMUNICABLE
DISEASES
Presumptive
TB
Non
responder
totreatment
;7
AllnotifiedTBpatients
H
E
PLHIV.
EPTB
Smear-ve/NAwith
X-ray
suggestiveofTB
includingpaediatric
Vulnerable
populations
ContactofDRTBpatient
NAAT
DSTB
Hmono/poly
Rresistancedetected Rresistancenotdetected
First
linetreatmentFL,SL-LPA&LC
DST|
FL
LPA
PresenceofnonDSTbasedcriteria&/orResistanceto
Lfx/Mfx(h),Km/Cm/Am&/orInhAmutationdetected
No
Unknown
Yes
Hresistance
detected
Hresistance
notdetectedHistoryofusefor>1month/intoleranceto
Mfx(h),Km,EtoorCfz
No
Yes SL
LPA&LCDST
Incaseofadditionalresistance,
failingregimen,drugintolerance
MDRTB
return
afterinterruption(>1m)longerMDR|
oremergenceofany
exclusioncriteria
Shorter
Alloral
AlloralHmono/poly
Continuefirst-linetreatmentregimen
TBregimenDR
TBregimen
L
ModifyregimenNAATincludeCBNAAT&TruNAAT
LCDSTwillbedoneasperthediagnosticalgorithm
FIG.3
IntegrateddrugresistantTBalgorithm(2019)
Source:(24)
forregulartreatmentandpossiblesideeffectsofthesedrugs
andtheconsequencesofirregulartreatmentorpre-mature
cessationoftreatmentandcoughetiquette.Itisadvisableto
involveclosefamilymembersduringthecounselling,
since=
familysupportisanessentialcomponentintn
management.Patientsshouldbeadvisedtoreportanyside
eifectsexperiencedbythem.Femalepatientsshould
receives
specialcounsellingonfamilyplanning.
Pretreatmentevaluationandtreatmentinitiationmustbe
doneattheDR-TBC(Drug-ResistantTBcentre)i.e.,DDR-
TBC(DistrictDR-TBC)andNDR-TBC(NodalDR-TBC).
TheconcernedDR-TBCcommitteeprovidescounselling,
initiatesactivitiesrelatedtoactivedrugsafetymonitoring
(aDSM)like,assessingthebaselinehistoryofknown
adverse/seriousadverseevents,biochemicalinvestigations,
ECGetc.,andinitiateshim/heronanappropriatetreatment
regimen.Caremustbetakentocorrectanyelectrolyte
imbalancebeforetreatmentinitiation.
MDR/RR-TBpatients(withoutadditionalresistance)and
Hmono/polyDR-TBpatientscanbeinitiatedonastandard
treatmentregimenatDDR-TBC.TheDDR-TBCshouldrefer
patientstoNDR-TBCformanagementofadditionaldrug
resistance,
regimen,returnaftertreatmentinterruptionof>1month,
emergenceofexclusioncriteriaforstandardregimen,for
expertopinion,managementofanycomplications
warrantingregimenchangeforconsiderationofnewerdrug
containingregimenorDSTguidedregimenbasedona
detailedassessment.
WhiletheMDR-TBcaseisundergoing
pre-treatmen
evaluation,theDTOshouldensureaninitialhomevisitt
verifytheaddressandmeetthefamilymembers.n
medicalofficerneedstoopenatreatmentcardfor
patientatthetimeofinitiatingthetreatment.Eachpatier
mustbegivenTBIdentityCard.ADOTprovider(who
ea
eitherbeahealthcareworkeroracommunityvolunte
shouldbeidentifiedinconsultationwiththepatient.
DOrcentrecanbeeitheratthesub-centre
ofthen
systemorinthecommunity.TheDOTprovidershou
giventrainingfordrugadministration,identificato
adverseeffectsduringtreatmentandthefrequeny
follow-up.
drugintolerance,contraindication,failing
R
UnderNTEP,the.followingarethestandara
regimens:
Providinghealtheducationandcounsellingtopatient
and
familymembers(23)
AllMDR-TBcasesareofferedreferralforcounsellingand
HIVtestingatthenearestcentre.Patientsshouldreceive
counsellingonthenatureanddurationoftreatment,need
1.AlloralHmono/polyDRTBregimen
2.ShorterMDRTBregimen
3.AllorallongerMDRTBregimen

54. TEURERCULOSIS 221
tandardregimenforinitiatingtreatmentof
IDR/RRTBorHmono-polyDRTB
canbeprovidecdtothepatient218yrs}forchildren&
adolescentsbetween6to17years,Dlncanbe
provided.UseofBdqfor6to17yrsandDlmfor3to
6yrsmaybeconsideredonlyafterapprovalofDCGI.
non-pregnantfemalesorfemalesnotonhormonalbirth
controlmethodsareeligible.Theyshouldbewillingto
Continuepracticingbirthcontrolmethodsthroughoutthe
freatmentperiodorhavebeenpost-menopausalforpast
2years;and
patientswithcontrolledstablearrhythmiacanbe
consideredafterobtainingcardiacconsultation.
Intensivephaseîegimenclass
mono/polyDRTBRresistancenotdetectedandHresistance)
AlloralHmono-poly|(6)LfxREZ
R-TBregimen"
DRRRTB
ShorterMDRTB
egimen"
Allorallonger
MDRTBregimen"
ltheintensivephaseisprolonged,theinjectableagentisonlygiven
threetimesaweekintheextendedintensivephase.
#ReduceLzdto300mg/dayafter6to8months.
aPyridoxinetobegiventoallDRTBpatientsasperweightband.
AlloralHmono/polyDRTBregimenisof6monthswithnoseparate
Continuationphase
(4-6)MíxhKm/
Am'EtoCfzZHhE
5MfxhCíz2E
(18-20)Bdq(6)LíxLzd"ClzCs
Exclusioncriteriafornewerdrugs(Bda/DIm)
Pregnancy&lactatingmother
currentlyhavinguncontrolledcardiacarrhythmiathat
requiresmedication;
havinganyofthefollowingQTcFintervalcharacteristics
atscreening:
QTcF2500atbaseline&normalelectrolytes.ECGtobe
repeatedafter6hoursandifbothECGsshow
QTcF>500thenthepatientshouldnotbechallenged
withcardiotoxicdrugs.
historyofadditionalriskfactorsforTorsadedePointes
e.g.heartfailure,hypokalaemia,familyhistoryoflong
QTsyndrome.
IP'CP
-ShorterMDRTBregimenisof9-11monthswith4-6monthsofIP
containinginjectablesand5monthsofCP
-lftheIPisprolonged,theinjectableisonlygiventhreetimesaweek
intheextendedintensivephase.
-AllorallongerMDRTBregimenisof18-20monthswithno
separateIP/CP
NewerdrugslikeBdqandDlmwouldbegivenfor6months
durationwhilethedoseofLzdwillbetaperedto300mgafterthe
initial6-8monthsoftreatment.
-ThisregimenwillalsobeusedfortreatmentofXDRTBpatientswith
20monthsduration.
DosageofDRTBdrugs
ThedosagefordrugsusedinvariousDRTBregimensby
weightbandsforadultsareenumeratedinTable2.These
areinaccordancetotheWHOrecommendeddosesof
Source:(24)
Inclusioncriteriafornewerdrugs(Bdq/DIm)
Patientaged>6yearshavingMDR/RRTB.(Bdq/DImanti-TBdrugsforacandpaediatricpatients.
TABLE2
DosageofDRTBdrugsbyweightbands
S.No.Drugs 16-29kg 30-45kg 46-70kg 70kg
450mg 600mg 750mgRifampicin(R)
2
300mg
600mg 900HighdoseH(H')
Ethambutol(E) sg
Pyrazinamide(Z)
Levofloxacin(Lfx)
Moxifloxacin(Mfx)
HighdoseMfx(Mfxh)
Bedaquiline(Bdq)
300mg 900mg
1600mg
mg
1200mg400mg
750mg
800mg
1250mg
3
4 1750mg 2000mg
1000mg
400mg
250mg 750mg 1000mg
200mg 400mg
600mg
400mg
400mg 800mg 800mg
Week0-2:Bdq400mgdaily
Week3-24:Bdq200mg3timesperweek
600mg
100mg
.
300mg 600mg
100mg
500mg
600mgLinezolid(Lzd)
10 50
250mg
200mgClofazimine(Cfz)
11
Cycloserine(Cs)
12Delamanid(Dim)
mg
750mg 1000mg
50mgtwicedaily(100mg)for24weeksin6-11yearsofage
1 100
mgtwicedaily(200mg)for24weeksfor>11yearsofage
mipenem/cilastatin
(Ipm/Cls)4 1
14
Meropenem(Mpm)
1000mgimipenem/1000mgcilastatintwicedaily
1000mgthreetimesdaily(alternativedosingis2000mgtwicedaily)
750mg
15Amikacin(Am500
mg 750mg 1000mg
16Capreomycin(Am)2
17 750mgidiiei
750mg 1000mg
1000mg
22gm
500mg
Kanamycin(Km)
18Ethionamide(Eto) 375
mg
500
mg
10
gm 14gm
875/125mg
BD
750mg
19
NaPAS(60%weight/vol)*
20Amoxyclav(Amx/Clv)(Inchild:875/125mg
WHO 80mg/kgin
2
divideddoses)BD
yridoxineIPdx) 50
mg
100
mg
.For
Hmono/polyresistantT5
16gm
875/125mg
(2morning+1
evening)
100mg
875/125mg
(2morning+1
evening)
100mg
*
adult
morethan60
years
of
age,doseofSLIshouldbereducedto1Omg/kg(maxupto750mg)
patientofPASwith80%weight/volumethedosewillbechangedto7.5gm(16-29kg);10gm(30-45kg);12gm(46-70kg)and16am(>70kal
rugscanbegivenindivideddosesinadayintheeventofintolerance
Source:(24)

55. 222
tEPDEMIOLOGY
OFCOMMUNICABLE DISEASESS
patienttoFLLPAandSl.LPAandcultureDST1
additionalresistance
isdetected,tneiPshouldbeprolon
nged
untilsputumsmearconverts.
thneintensivephaso
prolonged,theinjectableagentis
onlygiventhreetimo.
week.IPshouldbeextendedtobthor6thmonthbased
smearresultsatthe
endot4thandsthmonthof
treatmo
Thiswillbedoneforamaximumot2months(i.e..total
durationofIPisnotmorethanb
months).DurationofCPis
fixedfor5months.
Ifthepatientremainssmearpositive
at
theendof6thmonth
ortreatment,
thepatientwillbe
declaredas"Treatmentrailure,
re-evaluatedas
Der
integratedDRTBalgorithmandinitiatedonanappropriate
modifiedregimenbasedontheextended
DST.
Bedaquiline(24)
Week0-2Bdq400mg(4tabletsof100mg)daily
days
perweek)+otherdrugs;Week3-24:
Bdq200mg
tablets
of100mg)3timesperweek(withatleast
48hoursbetweendoses)foratotaldoseof600mgper
week+otherdrugs;andWeek25(startofmonth7)toend
O1treatment:Continueothersecond-lineanti-TBdrugsonly
asperNTEPrecommendations.
IftakingalightmealwithBdqandotheranti-iEdrugs,
patientsshouldnotconsumemilk-containingproductsatthe
sametime,asthecalciuminthesecandecreaseihe
absorption
ofFQs.Also,largefattymealsshouldbe
avoided,asthesecanimpairabsorption
ofsomeoftheother
anti-TBdrugs(Cs,H,etc.).
Thefollowingmedicationsaredisallowedduringthe
24-weekadministrationofBdqanduptoonemonthafterthe
lastdoseofBdqbecauseofpotentialdrug-druginteractions:
systemicuseofmoderateandstrongCYP3A4inhibitors,
e.g.azoleantifungals:ketoconazole,voriconazole,
itraconaz0le,fluconazole;ketolidessuchastelithromycin
andmacrolideantibioticsotherthanazithromycinfor
morethan2consecutiveweeks
systemicuseofstrongCYP3A4inducers,e.g.phenytoin,
carbamazepine,phenobarbital,St.John'swortand
ritamycins(rifampin,rifabutin,ritapentine);and
cholesterolloweringmedicationsofthe"statin"class.
AllorallongerMDRTBregimen
Totaldurationofallorallonger
MDRTBregimen
18-20months.Attheendofbthmonthottreatment,the
patientmustbereviewedbasedonthesthmonthculture
result.
If5thmonthcultureresultisnotavailableattheend
of6thmonth,deCISiontotapperthedoseotLzdtohalf
(300/150mg)willbebasedon4thmonthcultureresult.
If
the5thor4thmonthcultureresult(whicheverapplicable)
remainspositive,thedoseotLzd(6U0/300mg)andthe
regimenisextendedby
lmoremonth.
owever,the
durationofnewdrugs(BdqorDim)
islimitedto24weeks
only.DecisionforcontinuationofextendedIPwithzd
(600/300mg)beyond7thmonth,isdecidedbasedonthe
cultureresultsof6th/5thmonthandtheclinical/radiographic
response.ExtensionoflPbeyond8thmonth
isnot
permittedandpatientshouldbeswitched
toCP(i.e.total
durationoftreatmentisnotmorethan20months).
IS
Delamanid(24)
Allpatients>12yrsofagewillreceiveTab.Delamanid
100mg(twotabletsof50mg)orallytwiceadayfor
24weeksincombinationwithotherdrugs
intheregimen
whilepatientsbelonging
to6to11yrsofagegroupwill
receiveTab.Delamanid50mg(onetabletof50mg)twicea
dayfor24weekS.Remainingdrugs
inregimenwillbe
continuedbeyondthe24weeksofDimadministrationfor
theNTEPrecommendeddurationoftreatment.Itis
Ifthepatientcontinues
toremainculturepositiveor
revertsbacktoculturepositiveafter8monthsoftreatment.
thepatientisdeclaredas"Treatmentfailed",re-evaluated
as
perintegratedDRTBalgorithmandinitiatedonan
appropriatemoditiedregimenbasedontheextended
DSI.
ForXDRTBpatientsthedurationofallorallongerMDR15
regimenwouldbefor20months.
importantthatDlmbetakendailypreferablyaftera
standardmealtoimprovebioavailability.
TreatmentInterruptions&DRTB
Patientsshouldnotconsumemilk-containingproductsat
thesametime,ascalciumcandecreasetheabsorptionof
FQs.Also,largefattymealsshouldbeavoidedasthese
canimpairabsorptionofsomeoftheotheranti-lBdrugs
(Cs,H,etc).
ManagementofDRTBpatientswithtreatment
interruptionsandlosttofollow-up
AlleffortsmustbemadetoensurethatDRTBpatiets
co
notinterrupttreatmentorarelosttofollow-up.Actionshoud
betaken
topromptlyretrievepatientswhotailto
come
theirdailydosebythetreatmentsupporter.Thetollow
Strategiesàreapplicableforpatientswhointerrupttreaten
Patientswhomissdoses
:Inshorter
MDRTBregimen.du
misseddosesduringIPmustbecompletedpriortost
thepatienttoCPSimilarly,allmisseddoses
duringC
beadministeredpriortoendingtreatnment.Inlongeri
TBregimen,allmisseddosesduringtreatmentmu
administeredpriortoendingtreatment.
ExtensionoftreatmentinvariousDRTB
regimens(24)
AlloralHmono-polyDRTBregimen
TotaldurationofHmono-poly
DRTBregimenis
6months,canbeextendedto9months
incertainconditions.
Inpatientswithextensivedisease;uncontrolledcomorbidity;
extra-pulmonaryTB;
ifsmearattheendof4thmonth
is
foundpositive,theregimen1smodified,thetreatmentmay
beextendedto9months.
InCNS,skeletalandmilliaryTB,
treatmentmaybegivenuptoayear.Inpatientswhoremain
sputumsmearpoSitiveattheendof5monthorlaterof
treatment,theoutcomewillbedeclaredastreatmentfailure.
be
Patientswhointerrupttreatmentforlessthanonetment
wnenthepatientreturnstoresumetreatment,tne
redill
willbecontinued.However,thedurationoftreatrou
beextendedtocompletetheregimen.Theo
Cultureswillbedoneaspertheschedule.
ShorterMDRTBregimen
TotaldurationofshorterMDRTBregimenisfor
9-11months,dependingonlPduration.IPshouldbegiven
foratleastfourmonths.Afterfourthmonthoftreatment,if
theresultofsputummicroscopyisnegativethenCPshould
beinitiated.
Ifsputumsmearmicroscopydoesnotbecome
negativebythefourthmonthoftreatment,subjectthe
Patientswhoare"losttofollow-up"(interruptack
eatment
continuouslyforonemonthormore)andretu ost
to
treatment:SuchpatientswillbegivenanoutconNAAT
Tollow-up.Thepatientwouldbesubjectedtorepeathm
to
FL/SLLPAandLCDTasperthediagnosticsigns
o
estartwithappropriatetreatment.
lfthere
are>*s

56. TUBERCULOSIS 223
ifinterruptionismorethanonemonth,Bdqwillbe
permanentlydiscontinued.Suchpatientswillbegiven
anoutcomeof"Losttofollow-up(LTF0),registered
afreshandinitiateallorallongerMDRTBregimenwith
appropriatemodification.
Asputumspecimenwillbe
collectedforculture.Thecultureisolatemustbestored
forBdqDSTinfuture
oendingtreatment1failureforanyMDRRRTBpatientwith
ar
withoutadditionalresistancetosecondlinedrugs,the
afientshouldbeSwitchedtoanallorallongerDRTB
imenandevaluatedfurthertomodifyappropriatelybased
nDSTresultsitrequired.Ifapatienthasreceivedtheshorter
MDR
TBregimentormorethanonemonthandreturnsfor
oatmentafteraninterruptionofonemonthormore,the
patientisnotrestartedonashorterMDRTBregimen.
MDR/RRTBpatientsonBdq/DImcontainingregimen
ohointerrupttreatmentorare"losttofollow-up"or
recurrentDRTB:
PatientswhointerruptBedaquilinetreatmentduringthe
firsttwoweeksofBdqcourseandreturntoresumethe
DelamanidIfthepatientmissesoneormoredosesof
Dimduringtreatmentuptoamaximumofonemonth,one
shouldcontinuethetreatmentandcompletetheDlmforrest
oftheperiodwhichmayprolongtheDlmcontainingphase
beyond24weeksfrominitiationoftreatmenttomakethe
adjustmentofmisseddosage.
PatientswhoinitiatedonBda/DImcontainingregimen
andreturnaftertreatmentinterruptionofonemonthor
morewillbedeclaredas"losttofollow-up".Suchpatients
wouldnotbeconsideredeligibleforadministrationofsame
drug(Bdq/Dlm)anymore.
treatment:
ifinterruptionisupto7days,Bdqcontainingregimen
willbecontinuedtocompletethedosesandtheduration
oftreatmentwillbeextendedtocompleteIP.Follow-up
cultureswillbedoneaspertherevisedschedule;and
ifinterruptionismorethan7consecutivedays,Bdq
coursewillbereloaded(startedafresh)andafresh
specimencollectedforculture.Thecultureisolatemust
bestoredforBdqDSTinfuture
PatientswhointerruptBedaquilinetreatmentduring
3-24weeksofBdqcourseandreturntoresumetreatment(24)
Wherefurthertreatmentisconcerned,ifthepatienthas
anyindicationofatreatmentfailureorrecurrence,theNDR
TBCCommitteewillbecontactedtodiscusswhethers/he
shouldberetreated.Thedecisionwillbemadeonacase-to
casebasis,usingallavailablebacteriologicalandclinical
data.
ifinterruptionisuptoonemonth,Bdqcontainingregimen
willbecontinuedtocompletethedosesanddurationof
treatmentwillbeextendedtocompletefullcourseofBdq.
Follow-upcultureswillbedoneasperrevisedschedule;and
Follow-upevaluationsduringtreatment(24)
Thefollow-upevaluationscheduleduringtreatmentfor
DRTBpatientsmanagedwithvariousregimenclassesare
summarizedintheTable3.
TABLE3
Follow-upevaluationscheduleofDRTBpatientduringtreatmentbyregimen
Alloralregimenfor
HMono/PolyDRTB
Allorallonger
regimenforMDR/RR
Regimenclass ShorterMDRTB
regimen
Duration 6/9months(noseparateIP/CP)
Monthly
9-11months(4-6m
IP,5mCP)
MonthlyinIP
quarterlyinCP
Monthlyfrom3rdmonthonwards
tillendofIP,monthlyinextended
IPonlyifpreviousmonthS+ve
At3rd,6thandendofRx
18-20months(noseparateIP/CP)
Monthlyinfirst6months
Quarterlybeyond6months
Clinical+Wt.
Smear Monthlyfrom3rd WithcultureatC-DSTlabs
microscopy monthonwards
Culture Atendof3rd,6thand9th
month(ifapplicable)
Monthlyfrom3rdmonthonwardto
endof6months.Quarterlybeyond
6months,2consecutivemonthlyculture
ifanyculture+vefrom6monwards
FL&SLLPAandLCDST(Mfx1.0,
Lzd
Cíz&Z)ifanyculture+ve(3rd,6thand
endofRx)orsmear+veatendofIP
endofextendedIPandendofRx
DST NAAT,SLLPAandLCDST
asperalgorithmifsmear/culture
+veat3rd,6thand/or9thmonth
FL&SLLPAandLCDST(Mfx1.0,Lzd,
Cfz,Bdq&Dlm)ifanytimneculture+ve
atendof6monthsorbeyond6months
S.Creatinine MonthlytillSLIcourseis
completed
Ifinjectableisused,monthlytillSLI
courseiscompleted
Ifinjectableisused,every2monthstill
SLIcourseiscompletedandasandwhen
linicallyindicated
Asandwhenclinicallyindicated
15thday,monthlyinfirst6months,then
asandwhenclinicallyindicated
LFTquarterly,asandwhen
clinicallyindicated
Attheendof6months,endoftreatment,
asandwhenclinicallyindicated
At2weeks,monthlyinfirst6months,then
asandwhenclinicallyindicated
Audiometry Every2monthstillSLIcourseis
completedandthenasandwhen
clinicallyindicated
Asandwhenclinicallyindicated
Asandwhenclinicallyindicated
UPT
Asandwhenclinicallyindicated
AsandwhenclinicallyindicatedCBC/platelets
TSH&
LFT Atendof
IR,thenasandwhen
clinicallyindicated
AtendofIPendoftreatment,thenas
andwhenclinicallyindicated
Asandwhenclinicallyindicated
Asandwhenclinicallyindicated
andatendofRx
CXR
ECG At2weeks,monthlyinIP,thenasand
whenclinicallyindicated
Asandwhenclinicallyindicated
Asandwhenindicatedandincaseof
anyQTcFprolongation
Asandwhenclinicallyindicated
AsandwhenindicatedandincaseofS.Electrolytes
Na,K,Mg.Ca)
Specialist
consultation
Colourvisiontest
Asandwhenclinicallyindicated
anyQTcFprolongation
Asandwhenclinicallyindicated Asandwhenclinicallyindicated
Onceintwomonths(inchildren)Onceintwomonths(inchildren) Ophthalmicexamoncein3months
Source(24)

57. 224
EPIDEMIOLOGY OFCOMMUNICABLE DISEASES
CHILDHOODTUBERCULOSIS
Casesoftuberculosisinchildrenusuallyrepresent
between6-8percentofalltuberculosisintheagegroupof
under15years(4).Thesourceofinfectiontoachildis
usuallyanadult,oftenafamilymemberwithsputumsmear
positivetuberculosis.ThefrequencyofchildhoodTBina
givenpopulationdependson:(a)thenumberofinfectious
cases;(b)closenessofcontactwithaninfectiouscase;
(c)theageofchildwhenexposedtoTB;andtheage
structureofthepopulation.
strategycomprisesofcomponents.First,asinadults,childo
en
withTBareclassified,categorized,registeredandtreatedu
dailydoseshort-coursechemotherapyfromtreatmen
initiationtocompletion,givenunderdirectobservation
of
a
treatmentprovider(DOTprovider)andthediseasestatis
is
monitoredduringthecourseoftreatment.Basedontheir
pre.
treatmentweight,childrenareassignedtooneofthepre
treatmentweightbandsandaretreatedwithgoodqualityanti
TBdrugsthrough"ready-to-usefixeddosecombination
tabletsinpatient-wiseboxescontainingthepatients'completo
courseofanti-TBdrugs,madeavailabletoeveryregisteredTB
patientaccordingtoprogrammeguidelines.Indiai
thefirstcountrytointroducepaediatricpatient-wiseboxes(4
Childrenrarelyhavesputumsmear-positiveTBanditis
unlikelythattheyareapowerfulsourceoftransmissionofTB.
TuberculosisinchildrenismainlyduetofailureofTBcontrol
inadults.Theriskofinfectiontoachilddependsonextentof
exposuretoinfectiousdropletnuclei.Aninfantwhosemother
hassputumsmear-positivePTBhasahighchanceof
becominginfected.Thechanceofdevelopingdiseaseis
greatestshortlyafterinfection,andsteadilydecreasesasthe
timegoesby.Becauseofless-developedimmunesystem,
childrenunder5yearsofagearemorepronetodevelop
(upto20percent)thediseasemostlywithin2yearsfollowing
infection(26).ThecommonestageofchildhoodTBdisease
is1to4years.Youngageisariskfactorforspreadofdisease
tootherpartsofthebody,i.e.dissemination.
DiagnosisofPaediatricTB
InchildrenwithpresumptivepaediatricTB,everyattempt
mustbemadetomicrobiologicallyprovediagnosisthrough
examinationofappropriaterespiratory/non-respiratory
specimenswithqualityassureddiagnostictests.Diagnosis
of
tuberculosisshouldnotbemadeonlyonclinicalfeatures,
andfurtherinvestigationsarealwaysnecessarytoestablish
thediagnosis.
IncaseofsuspicionofpulmonaryTB,sputum
examinationshouldbecarriedoutamongchildrenwhoare
abletogivegoodqualityspecimens.CBNAATisthepreferred
investigationofchoice.
IfCBNAATisnotreadilyavailableor
testingisnotpossibleevenbyreferral,smearmicroscopy
shouldbeperformed.IfM.tuberculosisisdetected,byeither
ofmethodspatientisdiagnosedasmicrobiologically
confirmedpulmonaryTB.InsituationswhereM.tubeculosis
isnotdetectedorspecimenisnotavailable,chestX-rayand
Tuberculinskintest(TST)byMantouxtechniqueusing
2TU
ofPPDRT23shouldbedone.Forinterpretationandfurther
courseofaction,refertothediagnosticalgorithm
tor
childhoodpulmonaryTB(Fig.4).
InordertosimplifythemanagementofpaediatricTB,
RNTCPinassociationwithIndianAcademyofPaediatrics
(1AP)hasdescribedcriteriaforsuspectingTBamongchildren,
hasseparatealgorithmsfordiagnosingpuimonaryTBand
peripheralTBlymphadenitisandastrategyfortreatmentand
monitoringpatientswhoareontreatment.Inbrief,TB
diagnosisisbasedonclinicalfeatures,smearexaminationof
sputumwherethisisavailable,positivefamilyhistory,
tuberculinskintesting,chestradiographyandhisto
pathologicalexaminationasappropriate.Thetreatment
PersistentFever22weeks,withoutaknowncauseand/or
Unremittingcoughfor22weeksand/or
Wtlossof5%in3monthsornowtgaininpast3months
CBNAAT (onsputum)
*IfCBNAATisnotreadilyavailablesmear
microscopyshouldbeperformed
MTBnotdetectedORsputumnotavailable
MTBdetected
X-RayandTST
Microbiologically
confirmedTBcase
XRChighly
Suggestive
CXRNSshadows
TST-ve
CXRnormal
TST+ve
CXRnormal
TSTve
EvaluateforEPTB.Gastricaspirate/induced
sputumforCBNAAT
Givecourseof
antibiotics
Kerertoexpert
Lookfor
Persistentshadow
andsymptoms
Ve e alternate
cause
Nootherlikelyalternativediagnosis
clinicallydiagnosed
1TBcase
Gastricaspirate/induced
sputumforCBNAAT
Refertoexpertforwork-up
of
persistentpneumonia
e Ve
FIG.4
DiagnosticalgorithmforpaediatricpulmonaryTB
Source:(23)

58. TUBERCULOSIS 225
lo
followingtheflowchart,itisimportanttonotetheanexpert;(2)Includeatleast4-6
bactericidalmedicationto
whichthestrainisknowntoorlikelytobesusceptible;
)
Donotaddasingledrugtoafailingregimen;(4)Ensure
reatmentisgivenforatleast12monthsafterM.TBculture
nasconvertedtonegative;andextendtreatmentto
24monthsincaseofHIVinfectionorcavitatorylesions.
followingpoints:
10alaorithmisforchildrenwhoarelikelytohavedrug
ediseasei.e.havenotreceivedAlTpreviously
ouerandarenotpresumptivedrugresistantTB
cases
losttofolow-up,reCurrent,freatmentfailure,HIV).
9Propercharacteri2ationofsymptomsisveryimportant
sartingpoint.Weightlossornotgainingweightshould
alwaysbedocumentedwithappropriateandproper
Thechildrenaremanagedwithregimendesignswithout
newerdrugs,dependingontheDSTpattern.Thedosagefor
drugsusedinvarious
DR-TBregimensbyweightbands
for
paediatricDR-TBpatientsareenumeratedinTable4(38)
weighing.
Where
CBNAATisdoable,smearexaminationmaynot
hodone.Wheneversmearisusedfordiagnosisatleast
2samplesshouldbesentwhileasinglesampleis
subiectedtoCBNAAT.Ifaspecimenispositivebyanyof
TABLE4
WHOrecommendeddosesof
antiTBdrugsforpaediatricpatients
the
Drugs
these
methods,
microbiologicallyconfirmedTB.
4.
HighlysuggestivechestX-rayreferstoskiagrams
showingeithermiliaryorlymphadenopathy(hilaror
mediastinal)orchronicfibr0-cavitatoryshadows.Ifthe
radiologicalpictureishighlysuggestiveofTB,then
proceedtodofurtherinvestigationsirrespectiveofthe
TSTresultasthesensitivityofthetestisnot100%.
diseaseislabelled
DailyDose(Paediatric)
as
7-15mg/kgforpatientslessthan30kg:
maxdose300mgdaily
10-20mg/kgforpatientslessthan30kg:
maxdose600mgdaily
30-40mg/kgforpatientslessthan30kg:
maxdose2000mgdaily
15-25mg/kgoncedaily
5yearsandunder:15-20mg/kgsplitinto
twodoses(morningandevening)
Over5years:10-15mg/kgoncedaily
7.5-10mg/kg
15-20mg/kg
Isoniazid
1
Rifampicin
Pyrazinamide
Ethambutol
Levofloxacin
5.
NonspecificchestX-ray:Refertopatternsotherthan
highlysuggestivelikeconsolidationsinhomogenous
shadowsorbronchopneumonia,etc.
6.Wheneverindicated,alternativespecimens(gastric
aspirate/inducedsputum/bronchoalveolarlavage)should
becollectedbyaskilledhealthcareprovider,depending
uponavailableinfrastructureandsampleshouldbe
subjectedtoCBNAAT
7.AntibioticslikelinezolidoranyquinoloneorAmoxicillin-
clavulanicacidshouldnotbeusedastheyhaveanti-TB
Moxifloxacin
Ethionamide/
Protionamide
Cycloserine 10-20mg/kg
200-300mg/kgforpatients
lessthan30kg
10mg/kggiventhreetimesdaily
(pyridoxineshouldalsobegiven)
Limiteddata,but
1mg/kgonce
dailyhasbeengiven
80mg/kg(basedontheamoxicillin
component)intwodivideddoses
15-30mg/kgoncedaily(Max1000mg)
15-30mg/kgoncedaily(Max1000mg)
15-30mg/kgoncedaily(Max1000mg)
P-aminosalicylic
acid
Linezolid
action.
Clofazimine
8.Childrenwithpersistentsymptoms,nonspeciticshadows
andnegativesmearsandnegativeothersamples(GA/IS)
byCBNAATshouldbereferredtoexpertsforfurther
work-upofpersistentpneumonia.
9.AllTBcasesdiagnosedmustbeofferedtestingforHIv.
10.WheneverRifresistantresultisreportedonCBNAAT
Turthermanagementshouldbecarriedoutasperthe
guidelinesondrugresistantTB.
Amoxicillin
clavulanicacid7/1
Kanamycin
Amikacin
Capreomycin
ImipenemcilastatinMeropenemispreferredinchildren
Meropenem 20-40mg/kgintravenousevery
eighthours
Refertopage222
Refertopage222TBpreventivetherapy
Bedaquiline
Delamanid
.
he
doseofINHforchemoprophylaxisis10mg/kg
tansteadofearlierrecommendeddosageof mg/k9
uinistereddailyfor6months.TBpreventive
therap
shouldbeprovidedto:
1
Childrenatriskforperipheralneuropathy(e.g.malnutritionor
HIVco-infection)shouldalsoreceivepyridoxine5-10mg'dayas
therapeuticdose.
Source:(38)
asymptomaticcontacts(under6yearsofage)ofa
nearpositivecase,afterrulingoutactivediseaseand
LrespectiveoftheirBCGornutritionalstafus.
hemoprophylaxisisalsorecommendedforall
iv
ected
childrenwhoeitherhadaknown
exposuretoan
us
TBcaseoraretuberculinskintest(TST)positive
o
mm
induration)buthavenoactiveT5disease.
C.ATSTpositivechildren
TBINPREGNANCYANDLACTATING
WOMEN(23)
Beforeinitiatingtreatmentfortuberculosis,wome
childbearingageshouldbeaskedaboutcurrentorplanned
pregnancyand
counselledappropriately.Asuccessful
treatmentofTBisimportantforsuccessiuloutcomeof
pregnancy.Withtheexceptionofstreptomycin,thefirstline
anti-TBdrugsaresateforuseinpregnancy.Streptomycinis
oto-toxictothetoetusandshouldnotbeusedduring
of
whoarereceiving
Achildborntomother,who
wasdiagnosedtohave
TBB
nosuppressivetherapy(e.g.childrenwithnephrotic
ndrome,acuteleukemia,etc).
pregnancy.
Abreastfeedingwomanshouldreceiveafullcourseof
TBtreatment.Correctchemotherapy
isthebestwayto
preventtransmissionotTBtobaby.Breastfeedinghastobe
continued.AfterrulingoutactiveTB,thebabyshouldbe
given6monthsofisoniazidpreventivetherapy,followedby
BCGvaccination.Breast-teedingshouldnotbediscouraged.
in
pregnancy
ProvictoSnouid
receive
prophylaxisfor6months,
RCd
congenital:TBhasbeenruledoutfollowea
oy
vaccination
g-resistantTB
inchildren
childrennciplesoftreatmentof
drug-resistantTBin
Always
treatthechildin
consultation
with

59. 226
EPIDEM1oLOGYOF
COMMUNICABLE DISEASES
BCG
VACcCINATION
Themothershouldbeadvisedaboutcoughhygiene
measuressuchascoveringthenoseandmouthwhile
Coughing.sneezingoranyactwhichcanproducesputum
droplets.MothersreceivingINHandtheirbreastfedinfants
shouldbesupplementedwithvitaminB
RecommendeddoseofPyridoxineininfantsis5mg/day.
Eversince
KochdiscoveredM.tuberculosis,attemnt.
havebeenmadetoprepareaprophylacticvaccineagaine
tuberculosisusingeitherattenuatedorkilledfuberclebacill
InitiallyBCGwasgivenorallyduring1921to1925.The
first
humanwasvaccinatedbythe
intradermaltechnique
1927,RecognitionofthevalueofBCGcamein1948uh
nen
itwasacceptedbytuberculosisworkersfromalloverthe
worldasasafepreventivemeasure.
(1)
AIMTheaimofBCGvaccinationistoinduce
benign,artificialprimaryintectionwhich
willstimulatean
acquiredresistancetopossiblesubsequentinfectionwith
virulenttuberclebacilli,andthusreducethemorbidity
and
mortalityfromprimarytuberculosisamongthosemostatrisk
(2)VACCINEBCGistheonlywidelyusedlivebacterial
vaccine.
Itconsistsoflivingbacteriaderivedfrom
attenuatedbouinestrainoftuberclebacilli.Thebacilliused
forvaccineproductionaredescendantsoftheoriginal
CalmettestrainofBCG.Duetoditferentmethodsof
maintenanceinvariousvaccine-productionlaboratories,
manysubstrainshaveevolvedduringthepasttewdecades.
TheWHOhasrecommendedtheDanish1331"strainfor
theproductionofBCGvaccine.SinceJanuary1967,the
BCCLaboratoryatGuindy,Chennai,hasbeenusing
the
"Danish1331"strainfortheproductionofBCGvaccine
(39).Emphasishasbeenlaidonregularcheckingofthe
qualityofvaccinesattheInternationalReferenceCentrefor
BCGqualitycontrolatCopenhagen.
(3)TYPESOFVAcCINETherearetwotypesofBCG
vaccinetheliquid(fresh)vaccineandthefreeze-dried
vaccine.Freeze-driedvaccineisamorestablepreparation
thanliquidvaccinewithvastlysuperiorkeepingqualities
Present-dayvaccinesaredistributedinthefreeze-driedform.
(pyridoxine).
PregnancywithMDR-TB
AllMDR-TBsuspectsandpatientsofchild-bearingage
shouldbetestedforpregnancyaspartofpre-treatment
evaluationandwhileontreatment,ifthereisahistoryof
amenorrhoeaofanyduration.Theyshouldbeadvisedto
usebirthcontrolmeasuresbecauseofthepotentialriskto
bothmotherandfoetus.Oralcontraceptivesshouldbe
avoided.Useofbarriermethods(condoms/diaphragms),
TUDsarerecommended,basedonindividualpreferenceand
eligibility.ThemanagementofMDR-TBpatientswith
pregnancyissummarizedinFig.5.
PregnantDR-TBpatientsneedtobemonitoredcarefully,
bothinrelationtothetreatmentandprogressofthe
pregnancy.Thisapproachshouldleadtogoodresults,since
thepatientshouldbesmear-negativeatthetimeof
parturitionandmotherandinfantdonotneedtobe
separated.Breast-feedingshouldbeencouragedaslongas
thepatientissputumnegative
a
an
Intheenditmaybestatedthatthemainproblemof
chemotherapytodayisnottheneedtointroducenew
regimensormorepotentdrugs,buttoapplytheexisting
onessuccessfully.The
chemotherapyisadequateandregulardrugintake.Patient
complianceiscriticallyimportantthroughouttheprescribed
periodoftreatment.Allotherconsiderationsaresecondary.
cornerstoneofsuccessful
Durationofpregnancy
BCGvaccineisstableforseveralweeksatambient
temperatureinatropicalclimate,andforupto
1
yearifkept
awayfromdirectlightandstoredinacoolenvironment
preferablyrefrigeratedatatemperaturebelow10deg
C(40)
Thevacinemustbeprotectedfromexposuretolight
duringstorage(wrappedupinadoublelayerofredorblack
cloth)andinthefield.Normalsalineisrecommendedas
a
diluentforreconstitutingthevaccine,asdistilledwater
may
causeirritation.Thereconstitutedvaccinemaybeusedup
within3hours,andtheleft-overvaccineshouldbediscarded.
20
weeks 20weeks
AdvisedMTP
(4)DOSAGE:Forvaccination,theusualstrength
0.1mgin0.1mlvolume(41).Thedosetonewbornaged
below4weeksis0.05ml.Thisisbecausetheskinot
newbornisratherthinandanintradermalinjectionwithfuu
dose(0.lml)insomeofthemmightpenetrateintodeepe
tissueandgiverisetolocalabscessformationandentargeu
regional(axillary)lymphnodes.
MTPdone PatientunwillingforMTP
Start/continueStart/continue
shorter
MDR-TB
modifiedconventional
regimen
Start/continue
modifiedconventional
MDR-TB
regimen
(5)ADMINISTRATION
The standardprocedute
recommendedbyWHOistoinjectthevaccineintrader
usingaluberculinsyringe(Omegamicrostatsyringetite
WithaIcmsteel26gaugeintradermalneedle).Thesyr
andneedletechniqueremainsthemostprecisewa
administeringthedesireddose.Allothertecnss(e.g.,bifurcatedneedle,dermo-jet)arereportedctedaccurate,anddonotpermitthedesireddosetobemje
(+2).
Itthevaccineisinjectedsubcutaneouslyanabsces
morelikelytodevelop(43).Thesiteofinjection
stit
isJustabovetheinsertionoftheleftdeltoidmuscle
ontinjectedtoohigh,tooforwardortoobackward,theaorlymphnodesmaybecomeinvolvedandtender.Asa
injectionshouldproduceawhealof5mmindiamele
regimen
<12weeks:Omit
KmandEto;
.OmitKm;addPAS
tilldelivery
addPAS
.ReplacePASwith
Kmafterdelivery
andcontinuetill
endofIP
12weeks:Omit
Kmonly;addPAS
ReplacePASwith
Kmafterdelivery
andcontinuetill
endofIP
FIG.5
ManagementofDR-TBpatientswithpregnancy
Source:(38)

60. TUBERCULOSIS227
Thevaccinemustnotbecontaminatedwithanantisepticoteraent.Ifalcoholisusedtoswabtheskin,itmustbellowedtoevaporatebeforethevaccineisgiven.
6)AGE:Thenationalvaccinationpoliciesdifferfromnnuntrytocountry
(41).Incountrieswheretuberculosis
isArevalentandtheriskofchildhoodinfectionishigh(asinthenationalpolicyistoadministerBCGveryearlyinancu
eitheratbirth(forinstitutionaldeliveries)
orat
eeksofagesimultaneouslywithotherimmunizingagentsciIch
asDPTandpolio.BCGadministeredearlyinlifeprovides
highlevelofprotection,particularlyagainstthesevereformsofchildhoodtuberculosisandtuberculousmeningitis.
Incountrieswithalowprevalenceoftuberculosis,
perhapsthereisadiminishingneedforwidespreadBCG
vaccination.Inthissifuation,itwouldseemreasonableto
restrictBCGvaccinationtohighriskgroups,forexample,
hospitalpersonnelandtuberculin-negativecontactsof
knowncasesoftuberculosisparticularlymulti-drugresistant
TB(MDR-TB)(40,44).
(7)PHENOMENA AFTERVACCINATION
Twotothree
weeksafteracorrectintradermalinjectionofapotentvaccine,
apapuledevelopsatthesiteofvaccination.Itincreasesslowly
in
sizeandreachesadiameterofabout4to8mminabout
5weeks.Itthensubsidesorbreaksintoashallowulcer,rarely
open,butusuallyseencoveredwithacrust.Healingoccurs
spontaneouslywithin6to1Zweeksleavingapermanent,tiny,
roundscar,typically4-8mmindiameter.Thisisanormal
reaction(45).However,withoverdosage,thelocallesionand
thelaterscarmaybeconsiderablylargerandofirregularsize.
NormallytheindividualbecomesMantoux-positiveaftera
periodof8weekshaselapsed,butsometimesabout14weeks
areneeded.
onts
Studieshaveshownthattherangeofprotectionofferedby
BCGvariedfrom0to80percentindifferentpartsoftheworld.
Thefullexplanationforthevaryingdegreesofprotectionhas
yettobefound(52,53).Onesuggestionforwhichthereisan
increasingepidemiologicalsupport,isthatpriorexposureto
Somenon-tuberculousenvironmentalmycobacteriae.9.
M.vaccae,M.non-chromogenicum)mayhaveconferred
partialimmunityonthepopulationandthusmaskedthe
potentialbenefitofBCGvaccination(54).Thereisalso
evidencethatexposuretootherspecies(e.g.,M.kansasi,
M.Scrofulaceus)haveanantagonisticactionagainstBCG(55).
ThismaybeonereasonwhyBCGwasnotfoundtobe
protectiveintheSouthIndiantrial(45).However,infantsand
youngchildren,BCG-vaccinatedbeforetheyhadcontactwith
environmentalmycobacteria,derivedprotection.
ce
a
ean
with
and
risk.
teriad
an Thereisalargebodyofevidencewhichsupportsthe
conclusionthatBCGgivesanappreciabledegreeof
protectionagainstchildhoodtuberculosis(55).TheWHO,
onthebasisofanextendedreviewofBCGincludingthe
SouthIndiantrial(56)holdsthatitwouldseem
unreasonabletostopcurrentBCGvaccinationprogrammes
(53)andrecommendsthattheuseofBCGshouldbe
continuedasanantituberculosismeasure(56).
(10)REVACCINATION Thedurationofprotection
conferredbyBCGisamatterofdispute.Even90yearsafter
fhedevelopmentofthevaccine,itisnotknownwhether
boosterdosesareindicatedoradvisable.Infact,BCG
Used
gina
S
Dries,
ades.
nfor
the
gthe
CCine
fthe
retor
BCG
dried
revaccinationhasnotbeenincludedintheofficial
immunizationscheduleinIndiaundertheexpanded
programmeonimmunization.
(11)CONTRAINDICATIONS Unlessspecifically
indicated,BCGshouldnotbegiventopatientssufferingfrom
generalized
hypogammaglobulinaemia,tothosewithahistoryof
deficientimmunity(symptomaticHIVinfection,knownor
Suspected
lymphomaorgeneralizedmalignantdiseases),patientsunder
immunosuppressivetreatment(corticosteroids.alkylating
agents,antimetabolites,radiation),andinpregnancy.The
effectofBCGmaybeexaggeratedinthesepatients.
ation
lities.
1orm. eczema, infective dermatosis,
bient
ikept
ment
(40)
8)COMPLICATIONS :BCGhasbeenassociatedwith
adversereactionswhichinclude
ulcerationatthesite
prolongedsevere
vaccination,suppurativeof congenitalimmunodeficiency,leukaemia.
lymphadenitis,osteomyelitis,disseminatedBCGinfection
anddeath.Ulcerationandlymphadenitisoccursin
1-10percentofvaccinations,anddisseminatedinfection
OcCursinlessthanonepermillionvaccinations.The
disseminatedinfectionisusuallyassociatedwithsevere
abnormalitiesofcellularimmunity.Theriskofadverse
reactionsisrelatedtotheBCGstrainusedbydifferent
manufacturers,thedose,theageofthechild,themethodof
immunizationandtheskillofthevaccinator(46).
light
black
(12)DIRECTBCGVACCINATION DirectBCG
vaccination,i.e.,vaccinationwithoutapriortuberculintest.
hasbeenadoptedasanationalpolicyinmanydeveloping
countries,includingIndia.It
permitsamorerapidand
completecoverageoftheeligiblepopulation,whilereducing
thecost.NoadverseeffectshavebeenreportedevenifBCG
isgiventotuberculin-positivereactors(45).However.itis
soundpracticetoadministerBCGduringinfancybeforethe
childhashadcontactwithenvironmentalmycobacteria,than
to
resorttodirectBCGatalaterdate,whenthebenefitsof
BCGaredoubtfulasshownbytheSouthIndiantrial(57).
(13)IMPACT:BCGvaccinationislesseffectivein
controllingtuberculosisascomparedtoactivecase-finding
andchemotherapy,asBCGoffersonlypartialprotection.In
1982,aWHOExpertCommittee(58)concludedthat
althoughBCGvaccinationofuninfectedindividuals(usually
children)canpreventtuberculosisinthem,itcanhaveonly
arelativelysmallepidemiologicaleffectinthatitwillnot
contributesignificantiytothereductionintheoverallriskof
infectioninthecommunityasawhole.
I
asa
may
2dup
rdea.
gthis
aged
lfthereisalocalabscessformation,itshouldbetreated
byaspiration,incaseitdoesnotclearspontaneously.Ifthis
isnotsuccessful,itshouldbeincisedandtreatedwithlocal
applicationsdailywithPASorINHpowder.Thereisnoneed
for
systemictreatmentwithINH.Thepatientshouldbe
assuredoftheharmlessnatureofthelesion(47).Inorderto
avoidthesecomplications,thevaccinationshouldbestrictly
intradermalandnootherinjectionshouldbegivenfor
atleast6monthsintothearmwhichreceivedBCG
vaccine(48).
9)PROTECTIVE
VALUE:Thedurationofprotectionis
om15to20years.ThelocalBCGinfectiongeneratesan
immunityresponse,
which
evelopmentof,tuberculinhypersensitivityandwithit,
htul
eeper
arged
edure
maly
itea
nge
y
1ques
the
isassociatedwith
Ecied
ess3
poss
Someimmunity.Thefirstprospectivecontroltrial
5C6
showedittobe80percenteffectiveoveran
Servationperiodof20years(49).Sincethenseveral
planned,controlledtrialshavebeenconductedin
ProPartsoftheworld,includingthe"Tuberculosis
(14)BCGVACCINATION ANDHIVINFECTION
Followingareviewofrelevantdata,theGlobalAdvisory
CommitteeonVaccineSafety(GACVS)hasrevised
its
previousrecommendationsconcerningBCGvaccinationof
childreninfectedwithHIV.
ld
be
cen
FreventionTrial"
inSouthIndia(50,51).

61. 28
EPIDEMIOLOGYOFCOMMUNICABLE
DISEASES
cannotspreadTBinfectiontoothers.Overall,withou
treatment,about5-10percentofinfectedpersonsu
developTBdiseaseatsometimeintheirlives.Abouthalfo
thosepeoplewhodevelopTBwilldosowithinthefirst
two
yearsofinfection.Forpersonswhoseimmunesystems
weak,especiallythosewithHIVinfection,therisk
developingTBdiseaseisconsiderablyhigherthan
for
personswithnormalimmunesystems.Ofspecial
concern
arepersonsinfectedbysomeonewithextensivelydrua.
resistantTB(XDRTB)wholaterdevelopTBdisease,theso
personswillhaveXDRTB,notregularTBdisease.
ApersonwithlatentTBinfectionhasaskintestorbloodtest
resultindicatingTBintection;hasanormalchestX-ray
anda
negativesputumtest;hasTBbacteriainthebodythatarealive.
butinactive;doesnotfeelsick,cannotspreadTBbacteria
to
others;needstreatmentforlatentTBinfectiontopreventTB
disease.However,ifinfectedbyapersonwithMDRTBorXDR
TB,preventivetreatmentmaynotbeanoption(61).
WHOhadpreviouslyrecommendedthatincountrieswith
highburdenofTB,asingledoseofBCGvaccineshouldbe
iventoallhealthyinfantsassoonaspossibleafterbirth
inlessthechildpresentedwithsymptomaticHIVinfection.
However,evidenceshowsthatchildrenwhowereHlv
ntected,whenvaccinatedwithBCGatbirth,andwholater
developedAIDS,wereatanincreasedriskofdeveloping
iisseminatedBCGdisease.Amongthesechildren,the
enefitsofpotentiallypreventingsevereTBareoutweighted
oytherisksassociatedwiththeuseofBCGvaccine.GACVS,
therefore,advisedWHOtochangeitsrecommendationsuch
thatchildrenwhoareknowntobeHIV-infected,evenif
asymptomatic,shouldnolongerbeimmunizedwithBCG
vaccine(59).However,populationwithhighprevalenceof
HIValsohavethegreatestburdenofTB,andinsuch
populations,uninfectedchildrenwillbenefitfromtheuseof
BCGvaccine.Furthermore,withtheincreasingrangeand
COverageofinterventionstopreventverticaltransmission
frommothertochild
-includingearlydiagonsisofmaternal
HIVinfections;managementofsexuallytransmitted
infections;safedeliverypractices;maternalandinfant
preventiveantiretroviralmedicinesormaternalantiretroviral
therapy;andsafeinfantfeeding
-themajorityofinfants
borntoHIV-infectedmothersarenotinfectedandwould
alsobeexpectedtobenefitfromBCGvaccination(59).
Unfortunately,accuratediagnosisofHIVinfectioninthe
firstyearoflifereliesupondirectdemonstrationoftheHIV
virus,asmaternalHIVantibodyispassivelytransferredto
theinfantinutero.Currentlyavailableassaysthatcanbe
usedtodiagnoseHIVinthefirstyearoflifeareexpensive
andtechnicallydemandinginmanycountrieswith
generalizedHIVepidemics.WHOrecommendsthatthese
testsarefirstperformedatoraround6weeksage,yetthisis
oftenafterBCGvaccinationhasalreadybeengiven(60)
(15)COMBINEDVACCINATION:BCGmaybegivenat
thesametimeasoralpoliovaccine.DPTvaccinemayalso
begivenatthesametimeasBCG,butindifferentarm
withoutreducingtheimmuneresponsesorincreasingthe
rateofcomplications(50).MixedvaccinescontainingBCG
havenotyetbeenintroduced.
are
of
Healthcareinterventions
Currently,threemajorcategoriesofhealthcare
interventionsareavailableforTBprevention
1.TBpreventivetreatment;
2.preventionoftransmissionofTBinfectionthrough
infectionpreventionandcontrol;and
3.vaccinationofchildrenwithBCGvaccine.
Latenttuberculosistreatment(62)
ItisnotrecommendedthateveryonewithlatentTB
infection(LTBI)shouldhaveTBtreatment.Ratheritis
recommendedthatcertain"target"groupsshouldreceive
treatment.Themain"target"groupsconsideredtobemost
atriskforprogressingfromlatenttoactiveTBinclude
peopleinlowTBburdencountries:
whohavehadrecentcontactwithaninfectiouspatient:
withsilicosis;
infectedwithbothTBandHIV;
whohavebeenorwhoareinprison;
whoareimmigrantstoalowburdencountryfromahign
burdencountry;
Anincreasingnumberof
industrializedcountriesare
likelytoreconsidertheirBCGvaccinationpolicyduringthe
comingyears.TochangefromgeneraltoselectiveBCG
vaccination,anefficientnotificationsystemmustbeinplace
inadditiontothefollowing"lowendemicity"criteria:(a)an
whoarehomeless;
whoareanillicitdruguser;
whohavecertainclinicalconditions,orconditions
w
compromisetheirimmunesystem,suchaspeoplewitn
diabetes,andpeoplewithchronicrenalfailure.annualnotificationrateofsmear-positiveaverage
pulmonaryTBcasesbelow5per100,000;or(b)anaverage
annualnotificationrateoftubercularmeningitisinchildren
agedunderfiveyears,below
duringthepreviousfiveyears;or
(c)anaverageannualrisk
oftuberculosisinfectionbelow0.1percent(60).
Tosumup,BCGvaccinationisafundamentalcomponent
ofanationaltuberculosisprogramme.Despitethe
contradictoryevidenceofcontrolledtrials,thereisevidence
thatBCGplaysavaluableroleinpreventingsevereformsof
childhoodtuberculosis,vizmeningitisandmiliarytuberculosis.
Today,BCGvaccinationispartofWHOExpanded
Programmeonlmmunization.ThegreatestneedforBCG
vaccinationtodayisundoubtedlyinthedevelopingcountries
oftheworldwheretuberculosisisstillamajorhealthproblem.
InhighTBburdencountriesthepopulationsthat
are
moststronglyrecommendedforthetreatmentoflatentr
intectionarepeoplelivingwithHIV,andchildrenunder-ie
whoarehouseholdcontactsofpulmonaryTBcases.
per10millionpopulation
Recommendedregimens(62)
ded:
Currentlythefollowingthreeregimensare
recomme
Isoniaziddailyortwiceweeklyforninemonths
Isoniazidplusrifapentineonceweeklyfor12weesihis
Rifampicin(orrifabutin)dailyfor4months(VI
regimendotsmustbeused)
TheWHOalsorecommendstwootherregimeths
3
or
of
bf
LATENTTBINFECTION
Personswithlatenttuberculosisinfectionareinfected
withM.tuberculosis,butdonothaveTBdisease.Theonly
signofTBinfectionisapositivereactiontothetuberculin
skintestor1GRATBbloodtest.Theyarenotinfectiousand
4monthsofisoniazidplusrifampicindaily,andsix
modof
isoniaziddaily.In2019theresultswererepoant
2clinicaltrialslookingspecificallyatsideeffects.Anin
the
problemlimitingthetreatmentoflatentTBintectioiwas
oCcurrenceofadverseeventswithisoniazid.Theretoeations
recommendedthatinpatientswithoutcouont
Optio
ritampicinislikelytobethesafestTBinfectiontreatme

62. TUBERCULOSIS 229
auringthetreatment.Somestrainscanberesistanttooneor
moredrugs.
Rehabilitation
vears,therehasbeen
agooddealoffresh
ofrehabilitation,becauseofthe
hinkschievedintreatingpatientsondomiciliarylines
iththeirnormalworkandlife.The
In
recen
onthe
subject
Definitions
lease
refertopage207forclassificationofcasesbased
ondrugresistance.
SUCCe
nroportooredconditionsisbecominglessandless.The
undetthatneedrehabilitationarethosewhoarechronically
tillexcretingtuberclebacilli.Someofthosewho
rtionof
patientswhoneedrehabilitationandwork
ausesofdrug-resistanttuberculosis(25)
Drug-resistantTBhasmicrobial,clinicalandprogrammatic
causes.Fromamicrobiologicalperspective,theresistance
is
causedbyageneticmutationthatmakesadruginetfective
againstthemutantbacilli.Aninadequateorpoorly
administeredtreatmentregimenallowsdrug-resistantmutants
TObecomethedominantstraininapatientinfectedwith15.
able5summarizesthecommoncausesofinadequate
treatment.HoweveritshouldbestressedthatMDR-TBisman-
madephenomenonpoortreatment,poordrugsandpoor
adherenceleadtothedevelopmentofMDR-TB.
roups
and
arestil
resectionmayrequirerehabilitationtosuittheir
physicaland
mentalbilities.
Surveillance
Gurveillanceisanintegralpartofanyeffective
herculosisprogramme.1tsnouldbe
concernedwithtwo
hadlung
resection
tuberculos
distinct
aspects:(a)s anceofthetuberculosissituation,
taroxample,bymeasuringtheannualinfectionrates"
uhichwillguidetheepidemiologistandhealthadministrator
ht
indicatingwhetherthe
lBproblem
isstatic,increasingor
darrpasing;(b)surveillanceofcontrolmeasuresappliedsuch
as
BCGvaccinationandchemotherapy
Inallcountriesandespecíallythosewherethenumberof
casesoftuberculosisisrisingrapidlybecauseofthe
associationwithHIV,thedevelopmentofresistantstrainsof
tuberculosisisaseriousconcern.In2016,about0.60million
peopleworldwide,areestimatedtobeinfectedwithstrains
ofdrugresistanttuberculosis.Anaccuratepictureofdrug
resistanceisnotavailablebecausefewcountrieshavea
Roleofhospitals
Inspiteofeffectivedomiciliarytreatmentservices,there
willalwaysbesomepatientswhowillbeneeding
hospitalization.Themainindicationsforhospitalizationare
a)emergenciessuch
asmassivehaemoptysisand
spontaneouspneumothorax
c)managementofserioustypesoftuberculosissuchas
meningealtuberculosis,and(d)certainsocialindications,
suchaswhenthereisnoonetolookafterthepatientathome.
reliabledrugresistancesurveillancesystem(3).
ItisestimatedthatprimaryMDR-TBinIndiaisaround
2.8percent.Thedrugresistanceinre-treatmentcasesis
12(10-13)percent.AlthoughthelevelofMDR-TBinthe
countryislowinrelationtopercentageandproportion,it
translatesintolargeabsolutenumbers(64).
(b)surgicaltreatment
DRUGRESISTANCE
Alldrugsusedinthetreatmentoftuberculosistendto
produceresistantstrains.Theresistancemaybeoftwo
types:(a)PRIMARYORPRE-TREATMENT RESISTANCE
ltistheresistanceshownbythebacteriainapatient,whohas
notreceivedthedruginquestionbefore.Thatthisisnot
alwaysduetoinfectionoftheindividualwithdrug-resistant
Dacili,iswellknown.Itisanacceptedfactthatwhenthebacilli
arerapidlymultiplying,resistantmutantsappearirrespective
oftheadministrationofanyparticulardrug.Accordingtoone
ypothesis,drugresistanceisinducedbytransterence
tiroughwhatarecalled"episomes".Episomesarenon-
chromosomal
heritablegeneswhichcanpassfromone
bacterialcelltoanother.
Ifthereisadirectcontactbetweenthe
ning episomes,theepisomesleavetheresistantcell
nvadesusceptiblecells(63).(b)SECONDARY OR
HQUIREDRESISTANCE
Herethebacteriaweresensitive
arugatthestartofthetreatmentbutbecameresistantto
XDR-TBhasbeenreportedinIndiabyisolatedstudies
withnon-representativeandhighlyselectedclinicalsamples.
Themagnitudeoftheproblemremainstobedetermined
duetotheabsenceoflaboratoriescapableofconducting
qualityassuredsecondlinedrugsusceptibilitytest(10).
Ithasbeenobservedthatresistancetoisoniazidalone
doesnotaffecttheresultsoftreatmentsomuch,ifproper
regimensfortreatmentorretreatmentareprescribed,but
simultaneousresistancetoisoniazidandrifampicinlimits
severelytheresultsofthetreatment.
thep
drugduringthecourseoftreatmentwithit.
0acili
arenotkilledbytheanti-tuberculosisdrugsgiven
ThemostseriousdangerofMDRTuberculosisisthatitis
muchmoredifficulttotreat,evenwheresecondlinedrugs
areavailable.TreatmentofMDRtuberculosiscantakeat
leasttwoyearsandtheresultsarepoor.Secondlinedrugs
cost30timesasmuchasdrugsusedinSCCtreatmentof
non-resistanttuberculosispatients.PatientswithMDR
tuberculosismayneedtobehospitalisedandisolatedwhich
addstothecostoftreatment,topreventtransmissionof
primaryresistantstrainstoothers.Carefulprecautionsare
necessarytopreventtransmission,especiallytohealth
workerscaringforMDRtuberculosispatients(65).hasresIstance
means
thatcertainstrainsoftuberculosis
TABLE5
Causesofinadequate
treatment
Providers
programmes
dtequate
regimens
Patients:
Drugs
inadequate
supply/quality
inadequatedrugintake
Pooradherence
(orpoorDOT)
Lackofintormation
Dsence
ofguideliesor
happropriate
guidelines
on-compliance
withguidelines
equate
trainingofhealthsta
omonitoring
oftreatment
Non-availabilityofcertaindrugs
(stock-outsordelivery
disruptions)
Poorquality
Poorstorageconditions
Non-availabilityoffreedrugs
Socialandeconomicbarriers
Malabsorption
Substanceabusedisorders
Wrongdosagesorcombination
ContrognizedorfundedTB
grammes

63. 230 EPIDEMIOLOGY OFCOMMUNICABLE DISEASES
TheemegenceofXDR-TBandhighcasefatalityratein
patientswithHIVinfectionwasthesubjectofanemergency
consultationsheldinJohannesburgon7-8September,2006.
Theissuesincludedstrengtheningtreatmentadherenceto
achievehighlevelsofcompletion(285percent)forallTB
patientsensuringthatsecondlinedrugsusedtotreatMDR-TB
andADR-TBarestrictlycontrolledandproperlyused
accordingtoWHOguidelines.Thestepsrequiredtolimitthe
impactofMDR-TBandXDR-TBwereidentifiedand
incorporatedintoa7-pointplanofaction(66)
Intheshortterm,countriesshould:
EveninHIVpositivecases,tuberculosiscanbe
curerd
diagnosedintimeandireatedpropery.
ood
TBcontral
programmeisthebestthingthatcanbedonetocure
and
extendthelivesofHVpositiveindividuals.Withcorrect
T
B
treatment,theHIVpositivepersonhavingtuberculosis
gain,onanaveragetwoadditionalyearsoflife(67).
can
Epidemiologicalimpact
HIVandtuberculosisinteractinseveralways(65):
Reactivationoflatentinfection
infectedwithbothtuberculosisandHlV,are25-30
times
morelikelytodeveloptuberculosisdisease,than
infectedonlywithtuberculosis.his
isbecauseHIVstops
theimmunesystemworkingefectivelyandtuberculosis
bacilliareabletomultiplyrapidly.Indevelopingcountries
HIVassociatedtuberculardiseaseisverycommon
2.Primaryinfection:PeoplewithHivareatriskofbeing
newlyinfected,ittheyareexposedtotuberculosisbecause
theirweakenedimmunesystemmakesthemmore
vulnerable.NewtubercularinfectioninpeoplewithHIV
can
progresstoactivediseaseveryquickly.
People
whoare
1.developnationalemergencyresponseplansforMDR.
TBandXDR-TBandensurethatbasicTBcontrol
people
measuremeetinternationalstandardsforTBcare
andarefullyimplemented;
2.conductrapidsurveysofMDR-TBandXDR-TBusing
astandardizedprotocoltoassessthegeographicaland
temporaldistributionofXDR-TBinvulnerable
populations;
3.strengthenandexpandnationalTBlaboratory
capacitybyaddressingallaspectsoflaboratory
proceduresandmanagment;
4.implementintectioncontrolprecautionsinhealth-care
facilitiesaccordingtoWHOguidelines,withspecial
emphasisonthosefacilitiesprovidingcareforpeople
livingwithHIV/AIDS.
3.Recurringinfection:PeoplewithHIVwhohavebeen
curedoftuberculosisinfectionmaybemoreatriskof
developingtuberculosisagain.However,itisnotclear
whetherthisisbecauseofreinfectionorrelapse.
4.
Inthecommunity:Therearemorenewcasesofactive
tuberculosisbecausemorepeopleintectedwithtuberculosis
developactivedisease,andthosenewlyinfectedbecome
ill
faster.Thismeansthattherearemorepeopleinthecommunity
whoareinfectioustoothers.Largernumberofpeoplewith
activediseasemeanmorepeoplewilldiefromtuberculosis
unlesstheyaretreated.Theassociationoftuberculosiswith
HIVmeansthatpeoplesufferadditionaldiscrimination.
Communityeducationisneededtoincreaseawarenessthat
tuberculosisiscurableand,mostimportant,thatpeopleareno
longerinfectiousafterthefirstfewweeksoftreatment.
Inthelongterm,countriesshould:
5.establishcapacityforclinicalandpublichealth
managerstorespondeffectivelytoMDR-TBand
XDR-TB;
6.promoteuniversalaccestoantiretroviraltherapyfor
allTBpatientsthroughclosecollaborationwith
treatmentandcareprogrammestorpeoplelivingwith
HIV/AIDS;
7.supportandincreasefundingforresearchintothe
developmentofnewanti-tuberculosisdrugsandrapid
diagnostictestsforMDR-TBandXDR-TB,
DiagnosisoftuberculosisinpeoplewithH
PreventionofDrugResistanceSinceincomplete,
inadequateandirregulartreatmentisthemaincauseofdrug
resistance,thiscanbepreventedby(a)treatmentwithtwo
ormoredrugsincombination(6)usingdrugstowhichthe
bacteriaaresensitive,
and
(c)ensuringthatthetreatmentis
2.Focusonearlydetectionand
earlycare.
complete,adequateandregular.
Thesalientfeaturesareasfollows(23):
1.EmphasisonintegratedTBandHIVservices,eg.,HI
ScreeningatRNTCPdesignatedmicroscopycentre.
a.EarlydetectionofTBinPLHIV(personslivingwi
vAIDS):EarlysuspicionofTB-symptoms
ora
durationamongPLHIV;useofanexpandedcina
algorithmforTBscreeningthatrelieson
presence
fourclinicalsymptoms(currentcough,weignt
only
cough,
to
identifypatientswithpresumptiveTB;strengd
intensifiedcasefindingatART,LinkARIcentn
argetedinterventionprojectsforhighrisk
gro
Sand
Pleaserefertopage219fordetailsofguidelinesabout
managementofMDRandXDR-TB.
Tuberculosisandcomorbidities
SeveralmedicalconditionsareriskfactorsforTBand
poorTBtreatmentoutcomes.SimilarlyTBcancomplicate
courseofsomediseases.Itisthereforeimportanttoidentify
thesecomorbiditiesinpeoplediagnosedwithTBinorderto
ensureearlydetectionandimprovedoutcome.
feverornightsweats)instead
speciallyinjectiondrugusers;femalesex
wonfeon
menhavingsexwithmenetc.andofteringpIHV
CBNAATamongpresumptiveTBcasesamongTUBERCULOSISANDHIV
b.EarlydetectionandcareofHIVinfecteddrug-resie
TBpatientsbystrengtheningHIVtestinginpresuid
SIStant
WorldwidethenumberofpeopleinfectedwithbothHIV
andtuberculosis
isrising.TheHIVvirusdamagesthebody's
naturaldefences-theimmunesystem-
and
acceleratesthe
speedatwhichtuberculosisprogressesfromaharmless
infectiontolife-threateningcondition.Theestimated10per
centactivationofdormanttuberculoSisinfectionoverthelife
spanofanintectedperson,isincreasedto10percent
activationin
oneyear,ifHIvinfectionissuperimposed.
Tuberculosisisalreadytheopportunisticinfectionthatmost
frequentlykillsHlV-positivepeople.
DR-TBcases;ensureaccesstoCutu
d
nrompt
aru
SusceptibilitytestforHIVinfectedTBpatients,Pand
1inkageofHIVinfectedDR-TBcasestoARTcentres
promptinitiationofARTinHIVinfectedDKand
C.StrengthenHIV/TBactivitiesamongchildreu
pregnantwomen.
Inmostpeopleintheearly
symptomsoftuberculosisaresimilarasinpeopie
stagesofHIv
infection,
without

64. TUBERCULOSIS 231
on
inteontifvinginfectioussputum-smear-positivecases
more
difficultiftheyhaveadvancedHlVinfectionbecause:
treatment.ThisparadoxicalreactionoccursinHIV-infected
patientswithactiveTBandisthoughttobearesultof
immunerestitutionduetothesimultaneousadministration
ofantiretroviralandtuberculosismedication.Symptomsand
Signsmayincludehighfever,lymphadenopathy,expanding
intra-thoraciclesionsandworseningofchestradiographic
findings.Thediagnosisofparadoxicalreactionshouldbe
madeonlyafterathoroughevaluationhasexcludedother
aetiologies,particularlyTBtreatmentfailure.Forsevere
paradoxicalreactionsprednisone(1-2mg/kgfor1-2weeks,
thengraduallydecreasingdoses)maybeused(23).
HIVinfection.InareaswheremanypeoplehaveHIV
fection,
tuberculprogrammesshouldcontinuetofocus
throughmicroscopy.iowever,diagnosisoftuberculosisin
individualpatientsusing
thestandarddiagnostictoolscanbe
(alHIVpositivepeoplewithpulmonarytuberculosismay
haveahigherfrequencyofnegativesputum
smears.
Confirmingthediagnosismayrequiresputumculture.
(6)Thetuberculinskintestoftenfailstoworkinpeople
hoareHIVpositivebecause
itreliesonmeasuringthe
responseofaperson'simmunesystem.Iftheimmune
Nstem
hasbeendamagedbyHIV,itmaynotrespondeven
thoughthepersonisinfectedwithtuberculosis.HIVpositive
peoplewithtuberculosis,theretore,haveahigherfrequency
offalsenegativetuberculinskintestresults.
(c)Chestradiographymaybelessusefulinpeoplewith
HIVbecausetheyhavelesscavitation.Cavitiesusually
developbecausetheimmuneresponsetothetubercular
bacillileadstosomedestructionoflungtissue.Inpeoplewith
HIV,whodonothaveafullyfunctioningimmunesystem,
thereislesstissuedestructionandhencelesslungcavitation.
IsoniazidpreventivetherapyforPLHIVs
Isoniazidpreventivetherapy(IPT)isoneofthe3-l's
globallyrecommendedforpreventionofincidentTBamong
HIVinfectedindividuals.Itisthemosteffectivebactericidal,
antiTBdrugavailablecurrently.Whileitprotectsagainst
progressionoflatentTBinfectiontoactivedisease
1.ereactivation,italsopreventsTBreinfectioninpersons
whoareexposedtoopenTBcases.
AllchildrenlivingwithHIVwhohavecompletedtreatment
forTBsuccessfullyshouldreceivelNHforanadditionalsix
months.Thesechildrenwhodonothavepoorweightgain,
feverorcoughcurrently,areunlikelytohaveactiveTB.
ThosewhohaveabovesymptomsmayhaveTBandshould
beevaluatedforTBandotherconditions.Ifevaluationshows
noTB,suchchildrenshouldbeofferedIPTregardiessoftheir
age.ChildrenlivingwithHIVwhoaremorethan12months
ofageandwhoareunlikelytohaveactiveTBonsymptom-
basedscreening,andhavenocontactwithaTBcaseshould
receivesixmonthsofIPT(10mg/kg/day)aspartof
aa
comprehensivepackageofHIVpreventionandcareservices.
(d)Casesofextra-pulmonarytuberculosisseemtobe
morecommoninpeoplewhoareco-infected
Inshort-screenfortuberculosisusingsputumsmear
microscopy,
iftheresultispositive,starttreatment;ifthe
resultisnegative,butitissuspectedthatthepatienthas
tuberculosis,sputumcultureshouldbecarriedoutwhere
feasibletocontirmthediagnosisandgivetreatmenttothose
withpositivecultureresults.
TreatmentforHIVinfectedTBpatients
ProvidingIPTtopeoplelivingwithHIVdoesnotincrease
riskofdevelopingNHresistantTBlater.Therefore,concern
regardingdevelopmentonINHresistanceshouldnotbea
barriertoprovidingIPT(23).
BasedontheclinicalhistoryandinvestigationreportsART
medicalofficerwillcategorizepatientsasrifampicinsensitive/
rifampicinsensitivitystatusnotknown/clinicallydiagnosed
TBcase,priorhistoryoftakinganti-TBdrugs(Cat1/CatII),
andinitiatedailyantiTBtreatmentinFixedDosage
CombinationasperRNTCPguidelinesatARTcentreitself.
ThetreatmentofHIVpositiveindividualwithMDR-TBissame
asforHlVnegativepatients.However,treamentismore
difficultandadverseeventsmorecommon,hencerigorous
monitoringinthisparticulargroupofpatientsisrequiredin
ordertoensureadherencetotreatment,earlydetectionand
treatmentofadverseeventsreduce"losttofollow-up"(23).
ARTmustbeofferedtoallpatientswithHIVandTBand
HIVandMDR-TB,irrespectiveofCD,cellcount.Startanti-
tuberculosistreatmentfirstandthenstartARTassoonasTB
reatmentistolerated(between2weeksand2months).In
neabsenceofART,TBtreatmentalonedoesnot
SigniticantlyincreasetheCD,cellcount,nordoesit
sIgniticantly
decreasetheHIVviralload.TheuseofHighly
ActiveAnti-RetroviralTherapy(HAART)inpatientswithTB
canleadtoasustainedreductionintheHIVviralload.Itcan
AInctate
immunologicalreconstitution,anddecrease
defining illnessandmortality.Thisbeneiitisseen
actossdifferent
rangeofCD,counts.
FordetailsregardingHIVandTBco-activitiespleaserefer
tochapter7also.
TUBERCULOSISANDDIABETES
Diabeteshasbeenshowntobeanindependentriskfactor
fortuberculosisincommunitybasedstudyfromsouthIndia
andmultiplestudiesglobally.Itissuggestedthatdiabetes
accountsfor20
percentofalltuberculosisand10percentof
smearpositiveTB(23).Peoplewithweakimmunesystemas
indiabetesareathigherriskofprogressingfromlatentto
activetuberculosis.Theriskis2-3timeshigherthanpeople
withoutdiabetes.Alargeproportionofpeoplewithdiabetes
andTBarediagnosedverylate.
ItissuggestedthatallpeoplewithTBshouldbescreened
fordiabetesandscreeningforTBindiabetesshouldbe
considered,particularlyinsettingwithhighTBprevalence.
PeoplewithdiabetesandTBhaveahighriskofdeath
duringTBtreatmentandofTBrelapseaftertreatemt.As
diabetesiscomplicatedbypresenceofotherinfectious
diseasesalso,itisimportanttotakepropercareofdiabetes
inpatientssufferingfromdiabetes/TB(68).
NationalframeworkforjointTB-diabetescollaborative
activitiesareasfollows(23):
a.Activitiestoimprovediagnosisandmanagementof
diabetesamongTBpatients:
nadditiontoTBtreatment,allHIV-infectedTBpatients
be
providedaccess
to
care
andsupportforHIVdisease,
ng co-trimoxazolepreventivetherapytoreduce
amongPLHIVbypreventingopportunisticintections.
Immun
reconstitutionflammatorysyndrome(IRIS):
casionally,
atientswith
HIV-relatedTBmay
screeningofallregisteredTBpatientsfordiabetes
mellitus.
ensuringdiabetesmellitusmanagementamongTB
patients.
experien
radiooraemporaryexacerbationofsymptoms,signsof
nic
manifestationsofTBafterbeginning5

65. EPIDEMIOLOGY.OFCOMMUNICABLE DISEASES
notificationsfellby
more
than50%betweentheendofMarch
andlateApril2020,followingtheimpositionofanational
lockdown.Subsequently,therehasbeensomerecovery,buta
oftheendofJune,nottopre-Marchlevels.Decreasesoccurred
inboththepublicandprivatesectorasshowninFig.6.
TheimpactsofCOVID-19onTBservicesandmitigation
strategiesareasfollows(1)
b.ActivitiestoimprovediagnosisandmanagementofTB
amongdiabeticpatients
IntensitieddetectionofactiveTBdiseaseamong
diabeticpatients.
EnsuringTBinfectioncontrolmeasuresinhealth
caresettingswherediabetesmellitusismanaged.
EnsuringTBtreatmentandmanagementincomorbid
patients.
Impactsonhealthserviceavailability
Fewerhealthfacilitiesprovidingout-patientcarefor
peoplewithdrug-susceptibleTB
Fewerhealthfacilitiesprovidingout-patientcare
forpeoplewithmultidrug-orritampicin-resistant
(MDR/RR)TB
Fewerhospitalsprovidingin-patientcareforpeople
withdrug-susceptibleTB
Fewerhospitalsprovidingin-patientcareforpeople
withMDR/RR-TB
Reducednumberofout-patientvisitsforpeoplewithTB
PeoplewithTBaskedtoself-isolateathome
ReallocationofTBresourcestotheCOVID-19response
C.Jointmonitoringandevaluation.
d.TBpatientsdiagnosedwithdiabetesshouldreceivethe
samedurationofTBtreatmentwithdailyregimenas
non-diabeticpatients.
TBANDTOBACCO(23)
Tobaccosmokecontainstoxicchemicalswhichcause
disturbancesinthebronchialsurfaceofthelung.Italsoweakens
theimmunityofthepatienttofightwithTBbacteria.The
followingevidenceemergesfromseveralstudiesconductedto
lookattheassociationofTBandtobaccoinIndia:
Almost38%ofTBdeathsareassociatedwiththeuseof
tobacco.
ReallocationofNTPstaffatnationalorsub-national
PrevalenceofTBis3timesashighamongever-smokers
ascomparedtothatofamongnever-smokers.
MortalityfromTBis3to4timesashighamongever-
smokersascomparedtothatamongnever-smokers.
Smokingcontributestohalfthemaledeathsin25-69
agegroupsfromTBinIndia.
level
Reallocationoffunding
ReallocationofGeneXpertmachines
Mitigationstrategiestofacilitatecontinuedaccesstotreatment
ProvidingTBpatientswithatleasta1-monthsupply
ofanti-TBdrugs
Homedeliveryofanti-TBdrugs
EnablingTBpatientstonominateahousehold
membertocollecttheirdrugs
Expandedremoteadviceandsupportusingdigital
technologies
Exposuretotobaccosmokehasalsobeenfoundtoaffect
TBinthefollowingways:
Increasetheriskoftuberculousinfectionandtheriskof
developingTB.
Affectclinicalmanifestationsandincreaseriskofrelapse
amongTBpatients.
Affectmicrobiologicalconversion(sputumsmearor
culture)andoutcomeoftreatmentinTBpatients
Increasetuberculosismortalityanddrugresistanceto
anti-tuberculardrugs.
50,000 Lockdown
Total
WhenapatientgetsregisteredasaTBcase,thestatusof
tobaccouseisrecordedintheTBtreatmentcard.He/sheis
advisedtoquittobaccousewith5R'sRelevanceof
quitting;Riskofcontinuing;Rewardofquitting;Roadblock
toquitting;andRepeatateachvisit.
40,000
TUBERCULOSISANDCOVID-19(1)
30,000Public
sector
V
Sincethebeginningof2020,theCOVID-19pandemichas
causedenormoushealth,socialandeconomicimpacts,
whicharelikelytocontinuein2021andbeyond.Evenafter
someoftheseimpactshavebeenmitigatedorcontained,
there
wilIbemedium-andlonger-termconsequences,
includingforthetuberculosis(TB)epidemicandresponse.
The
pandemicthreatenstoreversetheprogress
made
towardsgloba
1TBtargets.Althoughphysicaldistancing
policiesmayhelptoreduceTBtransmission,thiseffectcould
beoffsetbylongerdurationsofinfectiousness,increased
householdexposuretoTBintection,worseningtreatment
outcomesandhigherlevelsofpoverty.Intheabsenceof
effectivemitigationstrategies,suchassocialprotectionand
healthinsurance,severeeconomiccontractionsandlossof
income(particularlyamongthemostvulnerablepopulations)
arelikelytoworsensomeofthefactorsthatdetermineTB
epidemics,especiallytheprevalenceofundernutrition.
Z20,000
10,000
Privatesector
2 34567
89101112131415161716
90
212223242520
Week,2020
INDIA
InIndia,theweeklyandmonthlynumberofTBcase
FIG.6
TrendsinweeklyTBcasenotificationsinIndiain2020.
beforeandafterlockdown
,
Source(1)

66. TUBERCULOSIS
235
PopulationsforTB(69)
14.StybloK.(1976).Int.J.Epi.5:63.
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Key
Peoplewho
have
Prisoners,sex
workers,miners,hospitalvisitors,
healthcareworkerSandcommunityhealth
workers.
PEOPLEWHO:
ive
inurbanslums
liveinpoorlyventilatedordustyconditions
Increased
2013revision.exposure
toI5
due
townere
they
8.Youmans,G.P.etal(1980).TheBiologicalandClinicalBasisof
nectiousDiseases,2nded,Saunders.
19.Gangadharan,P.R.J.(1980).Ind.J.Tuberculosis,27(3)108arecontactsofTBpatients,includingchildren
work inenvironmentsthatareovercrowdeed
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Famra,
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22.Comstock,G.W.(1978).Am.Reu,Res.Dis.,117:621.
ive
orwork
Migrantworkers,womeninsettingswithgender
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ndocumented
miarant"ers,
and
Peoplewho
havelimited
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ecnnicalandOperationalGuidelinesforTuberculosisContror
In
India,2016,MinistryofHealthandFamilyWelfare,NewDelhi.
accessto
qualityTB
Services
PEOPLEWHO: 24.Govt.ofIndia(2020),TrainingModulesforProgrammeManagersdr
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arefromtribalpopulationsorindigenous
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arehomeless
ive
inhard-to-reachareas
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havementalorphysicaldisabilitiess6pi
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Peopleat
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behavioura
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have
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29.Maxine,A,Papadakis,StephenJ.,Mcphee(2014),CurrentMedical
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sufferfromalcohol-usedisorders
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Despiteeffectivecase-findingandtherapeutictoolsand
declinesinmortalityandmorbidityratesinsomecountries,
fuberculosisappearstocontinueasanimportant
communicablediseaseproblem,worldwide,forseveral
decadestocome.Thechronicnatureofthedisease,the
abilityofthetuberclebacillitoremainaliveinthehuman
0odytoryears,theconcentrationofthediseaseintheolder
ge-groups,
theincreasedexpectationoflife,thehigh
vaenceofinfectionratesinsomecountries,therelatively
nreactivationrate,theemergenceofdrug-resistant
strains,associationoftuberculosisandHIVinfection,ana
vealthe
perpetuationof
thenon-specific
ererminants"ofthediseaseinthethirdworldcountries
mpedearapidconquestofthedisease.
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1ititstEts48.Banker,D.D.(1969).ModernPracticeinimmunization.Indian
References
WHO(2020),GlobalTuberculosisReport2020.
2U04),WeeklyEpidemiologicalRecord,23rdJan2004,No.4.
WHO(2018),
GlobalTuberculosisReportz010
Lt
ndia(2014),TBIndia2014,RNTCPAnnualStatusRepoOrt
nistryofHealthandFamilyWelfare,NewLDeihi.
O2015),Healthin2015,FromMDGs(MilenniumDe 52.Baily,G.V.J.(1981).Ind.J.Tuberculosis,28(3)117.stoSDGs(SustainableDevelopment60ais).
2016),FactSheetNo.104,March2016.
Eltmindia(2020),IndiaTBReport2020,NationalTuberculosis4.
angadharän,PR.(1981)Tubercle62:223.
JournalofMedicalSciences,Mumbai.
49.Aronson,J.D.etal(1958)ArchievesofInt.Med.101:881.
50.WHO(1979).BullWHO,57(5)819-827.
51.TuberculosisPreventionTrial,Madras(1979).Ind.J.Med.Res.,
70:349-363.
53.WHO(1980).WHOChronicle,34:119.
55.Wijsmuller,G.(1971).BullWHO45:633.
56.Dam,H.G.T.andHitze,K.L.(1980).BullWHo,58:37.
57.WHO(1980).TechnRepSer,No.652.
58.WHO(1982),Tech.Rep.Ser.No.671.
59.WHO(2007),WeeklyEpidemiologicalRecordNo.21,May25,2007.
60.WHO(2004),WeeklyEpidemiologicalRecord,No.4,23rdJan.2004.
61.CDC(2014),CentreforDiseaseControlandPrevention
Tuberculosis:FactSheet,Oct.2014.
62.TBFacts.ORG(2020),Informationabouttuberculosis,Jan.2020.
ogrammeAnnualReport,ZUZ
2020),TBdatageneratedbyWHO,2020.
TB
Sovt,of
I
aia(2010),TBIndia2010,RNTCPStatusReport,Central
0Govt stry.ofHealthandFamilyWelfare,NewDelhi
stonnndia
(2008),TB
India2008,RNTCPStatusReport,
Iam
11
WH MinistryofHealthandFamilyWelfare,NewDelhi.
wHO(1974).
Techn.
Rep.Ser.,No.53
13.WH
wLU14),StandardsforTBcare
inIndia.2WHO
(2016),
TuberculosisReport2016.

67. POLIOMYELITIS 243
includi0-1
yearold
scheduleddosesand
immunizationservices.Thechildren
infantsshouldreceivealltheir
d
duringroutine
poliovirusandVaccineDerivedPolioVirus(VDPV)isbeing
maintained.Environmentalsurveillanceiscontinuingat
foursiteswithestablishmentoftwonewsitesin2012.
receit
PPIdoses.Thereisnominimum
dscheduledOPVdoses(32).
interval
betweenPPI
GovernmentofIndiahasidentified107highriskblocks
Torpoliowhereamulti-prongedstrategyisbeing
mplementedtoensuresanitation,hygieneandclean
arinkingwaterinadditiontovaccinatingeachandevery
childoralpoliovaccine(OPV
.
MigratorypopulationfromUPandBihararebeing
IdentifiedinthestatesofPunjab,Haryana,Gujaratand
WestBengalandthesemigratory
childrenarebeing
cOveredduringtheSubNationalImmunization
LDay
(SNID)inUPandBihar.
7.Socialmobilizationactivitiesarebeingintensitied
by
involvingthelocalinfluencers,communityandreligious
leaderstoimprovecommunityparticipation
and
acceptanceofpoliovaccine.
8.Arollingemergencystockoforalpoliovaccine(OPV)is
beingmaintainedtorespondtoanywildpoliovaccine
(WPV)orcirculatingvaccinederivedpoliovirus
(cVDPV)detection
DortantimprovementinPPIduring1998hasbeenAn
the
o
ofvaccinevialmonitor.Colourmonitorsorlabels
arepuonvaccinebottles.Eachlabelhasacircleofdeep
blue
colour.Insideitisawhitesquarewhichchangescolour
and
graduallybecomesblue,ifvaccinebottleisexposedto
temperature.Whenthecolourofthewhitesquare
mesbluelikethatofsurroundingcircle,thevaccine
ld
beconsideredineitective.Thereby,thehealthworker
aneasilyascertainthatthevaccinebeinggiveniseffective
not.
Thismechanismhasbeenmademandatoryinall
arcineprocurementssince1998.Thisqualityassurance
willensurethatthechildrenwillhavebetterprotection
againstpolioin1999andthereafter.
FollowingrecommendationsfromtheIndiaExpert
AdvisoryGrouponPolioEradication(IEAG),several
strategieswereutilizedduring2005andearly2006to
imnrove
theimpactofSIAs:(i)developmentandlicensureof
monovalentOPVI(mOPVI)andmOPV3fortargeteduse
duringSIAsbasedonsurveillancedata;(ii)deploymentof
additionalperonneltoassistwithintensifiedSIAsintheStates
ofBiharandUPandinMumbaiCity;(ii)socialmobilization
targetedatreachingpopulationgroupsmissedduring
previousSIAs;(iv)useofmobileteamstovaccinatechildren
attransitpoints(e.g.railwayandbusstations)andonmoving
trains;and(v)increasedengagementandaccountabilityof
politicalleadersandofhealthstaffatalllevels.Tofurther
improvepopulationimmunityinthemostcriticalagegroup,
theIEAGaddedaspecificrecommendationatitsMay2006
meetingtoidentifyandtargetallneonatesinhigh-riskareasof
UPwitha"birthdose"ofmOPV1(33).
Thelastcaseofpoliointhecountrywasreportedfrom
HowrahofWestBengalwithdateofonsetofdiseaseon
13thJanuary2011.Thereafternopoliocasehasbeen
reportedinthecountry.On27thMarch2014,Indiawas
declaredasnon-endemiccountryforpolio.
Aspartofthepolioendgamestrategicplan,Indiahas
introducedIVPinthenationalimmunizationprogramme
from30thNovember2015andtOPV
carriedoutinApril2016(35).
AFPSURVEILLANCE PPIissupportedbyAFP
surveillancesystemsince1997.Itisbeingconductedthrough
anetworkofsurveillancemedicalofficers(SMOs),whoare
speciallytrainedandareresponsibleforadefinedarea.
AnationalsurveillanceteamispositionedinDelhi.TheSMOs
arelocatedatthestateheadquartersandatregionalplaces
incaseoflargerstates.Aregularweeklyreportingsystemhas
beenestablished.Asaresultofmoremeticuloussearch/
bOPVswitchwas
reporting,thenumberofreportedcasesofAFPincreased
from1,005in1996to11,675andthecompletenessofstool
specimencollectionimprovedmarkedlyfrom59percentin
1998to82percentattheendofSeptember2020(2).
References
ThestepstakenbytheGovernmenttoachievethetarget
ofpolioeradicationandmaintainthepolio-freestateareas
follows(34)
1.WHO(2017),WeeklyEpidemiologicalRecordNo.15,2018.
2
WHO(2020),WeeklyEpidemiologicalRecordNo.38,2020
3.WHO(2016),WeeklyEpidemiologicalRecordNo.36/37,9thSept.
2016.
All
statesandunionterritoriesinthecountryhave
aevelopedaRapidResponseTeam(RRT)torespondto
anypoliooutbreakinthecountry.AnEmergency
4
WHO,Immunization,VaccinesandBiologicals,AboutthePolio
EndgameStrategicPlan.
5EPI(2014),ThePolioEradicationEndgame,BriefonIPVintroduction,
OPVwithdrawalandroutineimmunizationstrengthening,March
2014.reparednessandResponsePlan(EPRP)hasalsobeen
developedbyallstatesindicatingstepstobeundertaken
ncaseofdetectionofapoliocase.
In
thestatesofUPandBihareverynewbornchildisbeing
dentifiedandvaccinatedduringthepolioimmunization
6.EPI(2015),Polio-GlobalEradicationInitiativePreparingfor
withdrawalofalloralpoliovaccine(OPV):ReplacingtrivalentOPV
withbivalentOPVfrequentlyaskedquestions,Feb.2015.
7.EPI,Polio-GlobalEradicationInitiative-PolioToday,KeyPointsabout
campaignsandisbeingtrackedfor8subsequentrounds.
3nordertoreacheveryeligiblechildduringthepulse
POlloround,apartfromthestrategyofvaccinatin9
containment.
8.WHO(2016),Immunization,VaccineandBiologicals,Fractionaldose
IPV.
idrenatfixedboothsandhousetohouse
visit,efforts
accinating
childrenintransitatrailwaystations,
elongdistancetrains,majorbusstops,markeer
ces,religiouscongregations,majorroadcrossings
etc.
Oughoutthecountryhavebeen
intensified.Special
sareestablishedinareasbordering
neighbouring
DeslikeWagahborderandAttaritrainstationin
Daband
Munabotrainstation
inBarmerdistricto
9
WHO(2016),WeeklyEpidemiologicalRecordNo.34,26thAug.2016.
10.GlobalPolioEradicationInitiative,DataandMonitoring,Surveillance
11.WHO(2010),WeeklyEpidemiologicalRecord,No.23,4thJune,2010.
12.WHO(2012),WeeklyEpidemiologicalRecordNo.38,21stSept.2012
13.Provoost,P(1985).ChildrenintheTropicsNo.156-157P58
14.Ichout,B.D.(1988).Med.Int.53:2189-2191.
15.Christie,A.B.(1980).InfectiousDiseases:EpidemiologyandClinical
Practice,3rded,ChurchillLivingstone.
16.Jewetz,
MelnickandAdelberg's.MedicalMicrobiology,26thEd,2013,
ALangeMedicalBook.
17.WHO(1983).Tech.Rep.Ser.No.693
18.ICMR(1975).ICMRBulletin,Jan.1975.
19.Krishnan,R.etal(1983).BullWHO,61(4)689-692.
Raja
n,to
ensurethatallchildrenunder5yearsofage
gfromacrosstheborderaregivenpoliodrops.
aremelyhighlevelof
vigilance
through
surveillance
sthe
countryforanyimportation
orcirculation
or

68. FHEPATITISSE
253
ChronichepatitisBintectioncanbetreatedwithdrugs.
eatmentcanslowtheprogressionofcirrhosis,reduce
incidenceoflivercancerandimprovelongtermsurvival.WHO
ocommendsthe
useoforaltreatments-tenofovirorentecavir,
cthesearethemostpotentdrugstosuppresshepatitisBvirus.
ThouTarelyleadtodrugresistanceascomparedwithother
drugs,aresimpletotake
(1pilladay),andhavefewsideeffects
co
requireonlylimitedmonitoring.Inmostpeople,however,
the
treatmentonlySupressesthereplicationofthevirus
Therefore,peoplewho
starthepatitisBtreatmentmust
continueitforlife.Treatmentusinginterferoninjectionsmay
beconsideredinsomepeopleincertainhigh-incomesettings,
asthismayshortentreatmentduration.Butitsuseisless
feasibleinlow-resourcesettingsduetohighcostandsignificant
adverseeffectsrequiringcarefulmonitoring(27).
inMarch2015,WHOlauncheditsfirst"Guidelinesforthe
prevention,careandtreatmentofpersonslivingwithchronic
hepatitisBinfectionTherecommendationsare(27):
promotetheuseofsimple,non-invasivediagnostictests
toassessthestageofliverdiseaseandeligibilityfor
treatment
prioritizetreatmentforthosewithmostadvancedliver
diseaseandatgreatestriskofmortality;and
recommendthepreferreduseofthenucleos(t)ide
analogueswithahighbarriertodrugresistance
(tenofovirandentecavir,andentecavirinchildrenaged
between2-11years)forfirstandsecond-linetreatment.
infections(mostlyasymptomaticbutsometimessymptomatic
intheformofacutehepatitis)mayevolveintochronic
infections(usuallyasymptomatic),whichmayfurtherevolve
intosequelae(cirrhosisandHCC)thatleadtomorbidityand
mortality.Astherecanbemore
infectionandmortality,viralhepatitissurveillanceneedsto
capturethesethreephasestofullydescribethe
epidemiologicalsituation.Estimationsofcurrent.prevalent
infectionsguidetestingandtreatment,whichwouldprevent
futuremorbidityandmortality.Currentmortalityfromthe
sequelaeofchronicinfectionsacquiredinthepastquantifies
thebaselineburdenandevaluatestheimpactofpast
interventions.Thethreecomponentsofviralhepatitis
surveillanceasshowninTable3,maybeimplementedby
differentactsofthepublichealthsystem.Thus,the
programmeresponsibleforviralhepatitisneedsto
consolidateandtriangulatesourcesofinformationfrom
thesedifferentsystemstodescribetheepidemiological
situationofHBVandHCVinfection.
20-30yearsbetween
GlobalHealthSectorStrategyonViral
Hepatitis2016-2021(28,29)
InMay2016,TheWorldHealthAssernblyadoptedthe
first"GlobalHealthSectorStrategyonViralHepatitis,
2016-2021".Thestrategyhighlightsthecriticalroleof
UniversalHealthCoverageandthetargetsofthestrategy
arealignedwiththoseoftheSustainableDevelopment
Goals.Thestrategyhasavisionofeliminatingviralhepatitis
asapublichealthproblemandthisisencapsulatedinthe
globaltargetsofreducingnewcasesofchronicHBVand
HCVinfectionsby90%andreducingdeathsduetoviral
hepatitisby65%(from1.4milliontolessthan500,000)by
2030.ItfocusesonHBVandHCVandproposestoincrease
thecoverageofpreventionsandtoscaleuptestingand
Theseguidelinesalsorecommendlifelongtreatmentin
thosewithcirrhosis;andregularmonitoringfordisease
progression,toxicityofdrugsandearlydetectionofliver
cancer(27).
Surveillance(27A)
InfectionswithHBVorHCVevolveinthreephases.New
TABLE3
Activitiesthatcontributetosurveillanceforviralhepatitis
3.Surveillanceforsequelae
1.Surveillanceforacutehepatitis
thatreflectsnewinfections
2.Surveillanceforchronic,
prevalenthepatitis
Combinationofdatafromdeath
certificates,andtestingof
patientswithcirrhosisandHCC
forHBVandHeVinfection
Regularbiomarkersurveys
Syndromicsurveillanceinthe
generalpopulation
Event-basedsurveillance
Activities
Enhancedcasereporting(with
in-vitrodiagnosisandcollection
ofinformationonriskfactors
Personspresentingwithacute
hepatitistohealth-carefacilities
(discreteonsetofsymptoms)
Personswithoutacutesymptoms
testedduringpopulationsurveys
Personsdiagnosedwithcirrhosis
andHCCPopulation
under
Surveillance
Usual
implementer
Vitalregistration
Sentinelsitescaringtorpatients
withcirrhosisandHCC
Cancerregistries
Communicabledisease
surveillance
Hepatitisprogrammein
coordinationwiththeother
actorsimplementing
biomarkersurveys
Communicabledisease
surveillance(ifcountrywide
Hepatitisprogramme
(ifsentinelsites)
ChronicHBVandHCV
infection
CasesofcirrhosisorHCC
ChronicHBVorHCVinfection
Presumptivecaseofacute
hepatitis
Confirmedcaseofacute
hepatitis(bytype)
Case
definitions
Serologicalevidenceofpastor
presentHCVintectiontouse
Objectiveof
thesurveillance
activity
Estimatetheprevalence
ofinfections
Modelincidencetrends
EstimatemortalityfromHBV-or
HCV-associatedHCCDetectoutbreaks
Describetrendsintype-specific
acutehepatitisandidentify
riskfactors
andcirrhosis
hepatitisBvirus;HCC:
hepatocellularcarcinoma,
HCV:hepatitisCvirus
Source(27A)

69. through
exposuretoinfectiousblood.Thiscan
oodtransfusi
254
LPDEMIOLOOY OF
COMMUNICAREE DiSEASES
nOcCur
treatment.ThekeyinterventionsoftheGlobalHealthSector
strategyforViralHepatitisare bloodproductsandorgantransplants;
(b)injections
ries
through:(a)receiptof
contaminatedbloo
given
1.Three-dosehepatitis
Bvaccinefor
infants
with
contaminatedsyringesand
needle-stickinjurie
iondruguse,and(d)bein
health-care
settings;(c)injection
borntoahepatitis
C-infectedmother.
Prevention
Interventions
2.PreventionofHBV
mother-to-child
transmissionusinghepatitisBbirth
doseorotherapproaches.
3.Bloodsafetyandinjectionsafety,
includinguseofengineereddevices.
4.Harmreductionforpersonswhouse
drugs.
Hepatitis
Cmaybetransmittedthroughsexwith
a
infectedpersonorsharingofpersonalitems
contaminated
withinfectiousblood,buttheseareless
common.Hepatifis
C
isnotspreadthroughbreast
milk,foodorwater,
orh
casualcontactsuchashugging,kissingandsharingfood
ar
drinkswithaninfectedperson.
5.DiagnosisofHBVand
HCV.
6.TreatnmentofHBVandHCv Incubationperiod
The
incubationperiodforhepatitisCis2weekstn
6months.
Treatment
Interventions
WHOcommissionedamathematicalmodel,which
suggeststhathepatitisBandCcouldbeeliminatedasapublic
healththreatby2030iftheresponsetoviralhepatitisreaches
theservicecoveragetargetsforfivecoreinterventionsof
prevention,testingandtreatment.Thestandardindicators,
2015baselineandthetargetsareasshowninTable4.
Symptomns
Followinginitialinfection,approximately80percentof
peopledonotexhibitanysymptoms.Thosepeoplewhoare
acutelysymptomaticmayexhibitfever,fatigue,decreased
appetite,nausea,vomiting,abdominalpain,darkurine,grey-
coloured
15-45percentofinfectedpersonssponteneouslyclearthe
viruswithin6monthsofinfectionwithoutanytreatment.The
remaining55-85percentofpersonswilldevelopchronic
HCVinfection.OfthosewithchronicHCVinfection,therisk
ofcirrhosisofliveris15-30percentwithin20years(31).
HEPATITISC
Aboutjointpainandjaundice
HepatitisCisacontagiousliverdiseasethatresultsfrom
infectionwiththehepatitisCvirus.
Itcanrangeinseverity
tromamildillnesslastingafewweekstoaserious,lifelong
illness.
Itisamongthemostcommonvirusthatinfectthe
liverandithasbeenshowntobeamajorcauseof
parenterallytransmittedhepatitis.
Everyyear,3-4millionpeopleareinfectedwiththe
hepatitisCvirus.About110millionpeopleareHCV
anti-bodypositiveand71millionarechronicallyinfected
andareatriskofdevelopinglivercirrhosisand/orliver
cancer.Morethan3,99,000peoplediedfromhepatitisC
-
relatedliverdiseasesin2016.Itisestimatedthatabout
2.3millionpeoplewereco-infectedwithHCVandHIV(27).
faeces,
Diagnosis(32)
Diagnosisofacuteinfectionisoftenmissedbecause
a
majorityofinfectedpeoplehavenosymptoms.Common
methodsofantibodydetectioncannotdifferentiatebetween
acuteandchronicinfection.Thepresenceofantibodies
againstthehepatitisCvirusindicatesthatapersonisorhas
beeninfected.ThehepatitisCvirusrecombinant
immunoblotassay(RIBA)andhepatitisCvirusRNAtesting
areusedtoconfirmthediagnosis.Diagnosisofchronic
Transmission
ThehepatitisCvirusismostcommonlytransmitted
TABLE
44
2030
target
2020Baseline
2015
Level Areas Indicators
target
1.Three-dosehepatitisBvaccineforinfants
(coverage%)
2Preventionofmother-to-childtransmissionofHBV:38%
hepatitisBbirth-dosevaccinationorother
approaches(coverage%)
3a.Bloodsafety:donationsscreenedwithquality
assurance(coverage%)
3b.Injectionsafety:;useofengineereddevices
(coverage%)
4.Harmreduction(sterilesyringe/needlesets
distributedperpersonperyearforPWID)
Service Prevention 82% 90% 90%
coverage
50% 90%
89% 95% 100%
5% 50% 90%
20 200 300
Testingand
freatment
5a.DiagnosisofHBVandHCV
(coverage%)
5b.TreatmentofHBVandHCv
coverage%)
<5% 30% 90%
80%eligible
treated
<1% 5million(HBV)
3million(HCV)
ImpactfeadingIncidence
toeliminationMortality
IncidenceofchronicHBVandHCVinfections
MortalityfromchronicHBVandHCVinfections
6-10million 90%
65%
-30%
1.46million-10%HBV:
hepatitisBvirus;HCV:hepatitisCvirus;PWID:personswhoinjectdrugs
Whiletheservice
coveragetargetisaboutoutputladoptionofreuse-preventioninjectiondevices),theC.5indicatorfocussesonoutcome(provisionofsafeinjections).
Source:(27A)

70. 94
EPIDEMIOLOGYOFCOMMUNICABLE DISEASEs
Globalstrategyfordenguepreventionand
control2012-2020(14)CONTROLMEASURES
Dengueisaglobalthreatthatrequiresaglobalrose
motesinvolvingallpossiblepartners.Theglobalstrategunrense
Mosquitocontrol
among
multisectoralThevectorsofDFandDHF(e.g.,A.aegypli)breedinand
aroundhousesand,inprinciplecanbecontrolledbyindividual
andconmunityaction,usingantiadultandantilarval
measures.Thesemeasuresareoutlinedinchapter14.
co-ordinationand
collaboration
andpartnersonintegratedvectormanagemenfapproach
sustainedcontrolmeasuresatalllevels.Thegoalsare
b.toreducedenguemorbiditybyatleast25percenti
2020;and
c.toestimatethetrueburdenofthediseaseby2015
a.toreducedenguemortalitybyatleast50percentby
020
by2.Vaccines(13)
CYD-TDVisaprophylactic,tetravalent,liveattenuated
iralvaccinedevelopedbySanofiPasteurinDecember
2015.Thevaccinationscheduleconsistsof3injectionsof
J.5mladministeredat6-monthintervals.Theindication
romthefirstlicensesisforthepreventionofdengueillness
causedbydenguevirusserotypes1,2,3,and4in
ndividuals9-45vearsor9-60yearsofage(dependingon
thelicense),livingindengueendemicareas.Thelowerlimit
oftheindicationat9yearsofagewaschosenduetoasafety
concerninchildrenaged2-5yearsidentifiedinthePhase3
clinicaltrials.
References
1
WHO(1993),MonographonDenguelDengueHaemorrhagicFee
CompiledbyPrasertThongchroen,KegionalPublication,
SEARO
No.22.
2.WHO(2020),FactSheet,23rdJune,2020.
3
WHO(2011),ComprehensiveGuidelinesforPreventionand
Cante
ofDengueandDengueHaemorrhagicFever,Revisedandexpander
edition,RegionalofficeofSEAR.
4.Govt.ofIndia(2018),AnnualReport2017-2018,DGHS,Ministry
of
HealthandFamilyWelfare,NewDelhi,
5.Govt.
ofIndia
(2019),NationalHeaithProfile2019,DGHS,
Ministry
of
HealthandFamilyWelfare,NewDelhi.
6Govt.ofIndia(2008),GuidelinesforClinicalManagementofDenque
Fever,DengueHaemorrhagicFeverandDengueShockSyndrome
MinistryofHealthandFamilyWelfare,NewDelhi.
7.WHO(2012),WeeklyEpidemiologicalRecord,No.8,24thFeb.2012
8.Jawetz,MelnickandAdelberg'sMedicalMicrobiology.24th
InternationalEd.(2007),ALangeMedicalPublication.
ded
CYD-TDVisavailableinasingle-dosevialorina
multidose(5-dose)vial.Itisafreeze-driedproducttobe
reconstitutedbeforeinjectionwitheitherasterilesolutionof
0.4%sodiumchlorideforthesingle-dosepresentationora
sterilesolutionof0.9%sodiumchlorideforthe5-dose
presentation.Afterreconstitution,the0.5mldoseistobe
administeredbythesubcutaneousroute.Thediluentis
providedasapre-filledsyringeforsingledosepresentation
orinavialforthemulti-dosepresentation.TheCYDTDV
denguevaccinecontainsnoadjuvantorpreservatives.The
shelflifeofCYD-TDVis36monthswhenstoredbetween
2°Cand8°C.Afterreconstitutionwiththesolventprovided,
thevaccinemustbekeptatbetween2°Cand8°Cand
protectedfromlight.InaccordancewiththeWHOmulti-
dosevialpolicy,anyreconstituteddosesremainingatthe
endofsessionshouldbediscardedwithin6hoursof
opening/reconstitutionorattheendofavaccination
session,whichevercomesfirst.
Govt.ofIndia(2006),NationalVectorBorneDiseaseControl
Programme,MinistryofHealthandFamilyWelfare,NewDelhi.Internet
10.WHO(2009),DengueGuidelinesforDiagnosis,Trectment
PreventionandControl,Newedition.
11.Govt.ofIndia(2014),OperationalGuidelinesNationaiProgrammefor
PreventionandControlofDengue,MinistryofHealthandFamily
Welfare,NewDelhi.
12.WHO(2012),HandbookforClinicalManagementofDengue.
13.WHO(2016),WeeklyEpidemiologicalRecord,No.3029thJuly
2016
14.WHO(2012),GlobalStrategyforDenguePreventionandContrl
2012-2020.
Themanufacturerstipulatesthatvacinationiscontra-
indicatedin:(1)individualswithahistoryofsevereallergic
reactiontoanycomponentofthedenguevaccineorafter
prioradministrationofthedenguevaccineoravaccine
containingthesamecomponents;(2)individualswith
congenitaloracquiredimmunedeticiencythatimpairscell-
15.Govt.ofIndia(2020),NationalGuidelinesDenguecasemanagement
duringCOVID-19Pandemic,2020,NVBDCPMinistryofHealthand
FamilyWelfare,NewDelhi.
the
MALARIA
mediatedimmunity:(3)individualswithsymptomaticHIV Malariaisaprotozoaldiseasecausedbyinfection
with
parasitesofthegenusPlasmodiumandtransmittedto
man
bycertainspeciesofinfectedfemaleAnophelinemosqult
Atypicalattackcomprisesthreedistinctstages:coldstage
hotstageandsweatingstage.Theclinicalfeaturesotmalad
varyfrommildtosevere,andcomplicated,accordingtO
Speciesofparasitepresent,thepatient'sstateofimmuniy
theintensityoftheinfectionandalsothepresene
Concomitantconditionssuchasmalnutritionorone
hetebrileparoxysmsoccurwithdetinite
intermittentperiodicityrepeatingeverythirdorfourth
y
dependinguponthespeciesoftheparasiteinvolved
isk
infectionorwithasymptomaticHIVinfectionwhen
accompaniedbyevidenceofimpairedimmunefunction;
4)pregnantorbreastfeedingwomen;andthatvaccination
shouldbepostponedinindividualswithmoderatetosevere
ebrileoracutedisease.
ace
3.Othermeasures
Isolationofthepatientunderbed-netsduringthefirstfew
days;individualprotectionagainstmosquitoes
Thepersonalprophylacticmeasuresarewearingoffull
sleevesshirtsandfullpants;useofmosquitorepellent
reams,liquids,coils,matsetc.,useofbed-netsforsleeping
nfantsandyoungchildrenduringdaytimetoprevent
mosquitobite.
Theenvironmentalmeasurementsaredetectionand
eliminationofmosquitobreedingplaces,managementof
ooftops,porticosandsunshades,propercoveringofstored
water,observationofweeklydryday.
2
diseases,
Bec
Problemstatement Ait
pre
WORLD
Ittookalmost30yearsfromtheendoftheo
lobal
MalariaEradicationProgramme(in1969)formalartaand
emergeasapublichealthpriorityinglobalheala00
developmentdiscourse.Althoughdatafrom1969to
ma

71. MALARIA 295
youngchildreninstabletransmissionareaswhohave
notyetdevelopedprotectiveimmunityagainstthe
mostsevereformsofthedisease
2.hon-immunepregnantwomenasmalariacauseshigh
ratesofrniscarriageandcanleadtomaternaideath
3,semi-immunepregnarntwomeninareasofhigh
transmission.Malariacanresuitinmiscarriageand
lowbirthweight.especialiyduríngfirstartdsecond
pregnancies
4.semi-immuneHIV-infectedpregnantwomeninstable
transmissionareas.duringalipregnancies.Wome
withmalariainfectionoftheplacentaalsohavea
higherriskofpassing
HIVinfectiontotheirnewborns:
.
peoplewithHIIAIDS:
6.internationaltravellersfromnon-endemicareas
becausetheylackimmunity.
T.immigrantsandtheirchildrenlivinginnon-endemic
areasandreturningtotheirhomecountriestovisit
friendsandrelativesaresimilarlyatriskbecause
ot
waningorabsentimmunity.
e
scarce,1hisperiod
wascharacterizedbyasenseoffailure
andonmentinthefightagainstmalaria.Duringthese
andabandredsolmillionsofpeoplewereinfectedwith
3deens
ofmillionsmostlyinsub-SaharanAfrica
nsofhouseholdslailedfoemergeoutofpoverty
thcatastrophichealthexpenditures,
died,
mill
as
they
struggled
ofthousandsofpregnantwomendiedduring
withlowbirth-weight,potentiallychildrenwereborn
oin
foearlydeathorlifelongdisability.Millionsof
delivery
tomalaria-relafedcomplications,andmillions
childre
whosurvived,struggledwithlearningastheydealt
with
frequentabsenteeismduetomultipleepisodesof
laria,chronicanaemia,seizuresorcognitiveimpairment
consequencesofiniectionandseveredisease.Hugeblows
dealttothegrowthofalreadyweaknational
were
economies,andtheirattemptstobuildviablehealthsystems
werehamperedbylostproductivityandhighdemandfor
healthcare.
Againstthisbackground,thefirst2decadesofthe21st
centuryrepresentagoldenerainthehistoryofmalaria
control.Theworldpulledtogethertofightmalaria,
deliveringoneofthebiggestreturnsoninvestmentinglobal
health.Theunprecedentedscale-upofmalariainterventions
overthisperiodhasledtoconsiderablereductionindisease
incidenceandmortality.Theseeffortscoincidedwithother
trends
andchangesthathavehadapositiveimpacton
malaria,includingaperiodofconsiderableeconomicgrowth
anddevelopment,infrastructureandhousingimprovements,
rapidurbanization,andgeneralimprovementsinhealth
systemsandpopulationhealth.Theindirecteffectofthese
gains
ontheoverallhealthofpopulationsandeconomiesis
substantial(2).
Malariaaffectsmainiypoor.underservedandmarginalized
populationsinremoteruralareaswhicharecharacterizedby
inadequatecontrolmeasuresandlimitedactesstoheaith
care.Highermalariaprevalencehasbeenreportedamong
ethnicandtribalgroupslivinginremoteforestedandborder
areas,aswellasamongmobileandmigrantpopulations.
Thechildhooddeathsresuitmainlyfromcerebralmalaria
andanaemia.Fatalityratesofi0-30percenthavebeen
reportedamongchildrenreerredtohospitalwithsevere
malaria.However,theseratesareevenhigherinruraland
remoteareaswherepatientshaverestrictedaccessto
adequatetreatment.Malariaalsocontributesindirectiyto
illnessanddeathsfromrespiratoryinfections,diarrhoeai
diseaseandmalnutrition.Deathsfrommalariaincountries
outsideSub-SaharanAfricaoccurprincipallyinnon-
immunepeoplewhobecomeiníectedwithPfalciparum.
Underreportingofmalariacasesanddeathsremaina
majorchallenge.Drug-resistantparasites.poortreatment
seekingbehaviourandthepresenceofcounterteit
antimalarialdrugsfurtherhindercontrolefforts.Resistanceoi
P.falciparumtothe4-aminoquinolinesandsultadoxine-
pyrimethamineiswidespreadinalmostallcountriesofSEAR.
withvaryinglevelsofseverity.Resistancetomatloquinewas
reportedfromMyanmarandThailand.Quininehasreduced
susceptibilityinThailand.Withprogressirommono-to-
multidrugresistance,allmalaria-endemiccountriesthathave
falciparummalariaadoptedthehighlyettectiveartemisinin
basedcombinationtherapy(ACT).
Globally,therewereanestimated229millionmalaria
casesin2019in87malariaendemiccountries.The
proportionofPvivaxwasabout3percentin2019,down
fromabout7percentin2000.Malariacaseincidence,i.e.
casesper1000populationatriskreducedfrom80in20000
to57in2019globally.Indiacontributedtothelargest
absolutereductionintheSouth-EastAsiaRegionfrom
about20millioncasesin2000to5.6millionin2019.The
South-EastAsiaRegionaccountedforabout3percentoi
theglobalmalariacases.
Globally,
malariadeathshavereducedsteadilyoverthe
period2000-2019,from7,36,000in2000to4,09,000in
4U9Themortalityrate,i.e.deathsperlakhpopulationat
SK,reducedfromabout25in2000to10in2019.The
percentage
oftotalmalariadeathsamongchildrenaged
under5years
was84percentinyear2000,and67percent
h
207
n
South-EastAsiaRegion,malariadeathsreduced
percent,from35,000in2000to9,000in2019.India
Ccountedforabout86percentofallmalariadeathsinthe
onGlobally,anestimated1.5billionmalariacasesand
On
malariadeathshavebeenavertedintheperiod
U19,Mostofthecases(82%)anddeaths(94%)
ReereinAfricanRegion,followedbySouth-EastAsia
egion(10%cases
and3%deaths).
Thecoverageofindoorresidualsprayingwithinsecticides
(IRS)remainslow(42percent).lnsecticide-treatednetshave
beenintroducedinalmostallcountriestosupplementIRS
efforts,butthecoverageremainsextremelylow
INDIA
Malariacontinuestoposeanajorpublichealt-
threatinIndia,patticularlydue
falciparumwhichispronetocomptications.InIndiaabou
21.98percentpopulationiivesinmalariahightransmissior
(1case/1000population)ateasandabout67percent
ie
lowtransnmission(0-lcase/1000population)areas
(3;
About91percentofmalariacasesand99percentofdeath
duetomalariaisreportedtromNorth-easternstates
Chhattisgarh,Jharkhand,MadhyaPradesh,Odisha,Andhr
Pradesh,Maharashtra,Gujarat,Rajasthan,WestBengalan
Karnataka.However,theotherstatesarealsovulnerabl
toPlasmodium
Altein33moderatetohightransmissioncountriesin
nRegion, there
were
anestimated33million
ancles,ofwhich35percent(12million)wereexposea
alariainfection
duringmalaria
infection
duringregnancyinthese33countries
Thespecific
riskgroupsformalariaincludesthefollowing
Sulled
in8,22,000
childrenwithlowbirth-weight(2).
pregnancy.Itisestimatedthat
Population1)

72. 327JAPANESE
ENCEPHALITIS
millionpopulationisatrisk.JEis
InInaundertheumbrellaofAcuteEncephalitis
therefore,thedatareportedfromstates
includingJEcases.During2016,11,651
,301deathswerereported.Thisincludes
mostimportantvectorinSouthIndia(7).Thesemosquitoes
generallybreedinirrigatedricefields,shallowditchesand
pools.Thericefieldsareprobablythemostimportant
breedingplaces.Thesemosquitoesarezoophilic,teedin9
primarilyonvertebratehosts.Femalemosquitoesgetintected
aiterfeedingonaviraemichost,andafter9-12days
Incubationperiod,theycantransmitthevirustootherhosts.
dia
about375
reporte
Syndrome
(AES),
fortotal
AES5i
are
1.676JEcasesand283deaths.In2017,13,672AEScases
abeenreported.Inyear2018,11,382caseswith
687deathswerereported
duuefoAESwith1,674casesand
182deathsduetoJE(5.
Thestate-wisereportedcasesof
EScaseswith
1,3
and
097deathsincludit2,180JEcasesand254deaths
JEINMAN
Theincubationperiodinman,followingmosquitobiteis
notexactlyknown.Probably,itvariesfrom5-15days.Not
allindividualsbittenbyinfectedmosquitoesdevelop
disease.Theratioofovertdiseasetoinapparentinfectionis
about1:250.Thuscasesofencephalitisrepresentonlythe
tipoftheicebergcomparedtothelargenumberof
inapparentinfections.EncephalitiscasesduetoJEmay
showascattereddistribution.
JEareasshowninTable2.
TABLE2
State-wisereportedcasesanddeathsdueto
JEinIndia2016-2018
2016 2017 2018(P))
CasesDeathsCasesDeathsCasesDeaths
State
Thecourseofthediseaseinmanmaybedividedinto
threestages:(a)PRODROMAL STAGE
:Theonsetofillness
isusuallyacuteandisheraldedbyfever,headache
gastrointestinaldisturbances,lethargyandmalaise.The
durationofthisstageisusually1-6days.(b)ACUTE
ENCEPHALITICSTAGE:Feverisusuallyhigh,38to
40.7deg.C.Theprominentfeaturesarefever,nuchal
rigidity,focalCNSsigns,convulsionssignsofraisedintra-
cranialpressure,difficultyofspeech.dystonia.ocular
palsies,hemiplegia,quadriplegia,extra-pyramidalsignslike
coarsetremorsandalteredsensoriumprogressinginmany
casestocoma.(c)LATESTAGEANDSEQUELAEThis
stagebeginswhenactiveinflammationisatanend,i.e.,the
temperatureandESRtouchnormal.Neurologicalsigns
becomestationaryortendtoimprove.Convalescencemay
beprolongedandresidualneurologicaldeficitsmaynotbe
uncommon(3).Thecasefatalityratevariesbetween
20-40percent.Theaverageperiodbetweentheonsetot
illnessanddeathisabout9days(3).
427 92 604 94 509 94Assam
Bihar
Jharkhand
Karnataka
Manipur
Meghalya
Odisha
TamilNadu
Tripura
UttarPradesh
WestBengal
100 25 74 11 70 11
e
47 29 66
26 2 35
47 1 186 10 57 3
47 4 48 4 90 6
242 42 79 143 0
51 127 2 147 0
98 90 59
VSIT.a}
410 73 693 93323 25
01.
174 39 165 40 140 35
ASz
IndiaTotal 1,6762832,1212571,639179
P-Provisional
Source:(5)
Tra
Epidemiologicalfeatures
Unlikethedengueviruses,JEvirusinfectsseveral
extrahumanhosts,e.g.,animalsandbirds.Available
evidenceindicatesthatthebasiccyclesoftransmisionare
(a)PigMosquito>Pig
(6)TheArdeidbirdMosquitoArdeidbird
Thediseaseistransmittedtomanbythebiteofinfected
mosquitoes.Manisanincidental"dead-end"host.Manto
pradi
thees ConfirmationofasuspectedcaseofJErequires
laboratorydiagnosis.TheaetiologicaldiagnosisofJEis
mainlybasedonserologyusinglgM-captureELISAwhich
detectsspecificlgMinthecerebrospinaliluidorintheblood
ofalmostallpatientswithin7daysofonsetofdisease.Other
methodsincludeconventionalantibodyassaysonpaired
seraforthedemonstrationofasignificantriseintotal
JE-specificantibody,aswellasadot-blotlgMassay,
suitableforuseinthefield.Thevirusisrarelyrecoveredin
tissueculturefrombloodorCSF,butmaybefoundin
encephaliticbrainatautopsy.JE-viralRNAisrarely
demonstratedintheCSF(8).
10
man
transmissionhasnotsofarbeenrecorded.
Upera
(a)Animalhosts:Amongtheanimalhosts,pigshave
ncriminatedasthemajorvertebratehostsforJEvirus.
nsome
places,upto100percentofpigsmaybeintected
witnJEvirus.InfectedpigsdonotmanifestanyoveTE
ymptomsofillnessbutcirculatethevirussothaat
OSquitoesgetinfectedandcantransmitthevirustoman.
Cags
arethusconsideredas"amplifiers"ofthevirus(6).
al
andbuffaloesmayalsobeinfectedwiththeJEvirus;
ControlofJE
(a)VACCINATION:Vaccinationofpopulationatriskhas
beenrecommended.Currently,thethreetypesofJE
vaccinesinlarge-scaleuseare
:(i)themousebrain-derived
purifiedandinactivatedvaccine,whichisbasedoneithetheNakayamaorBeijingstrainsoftheJEvirusane
producedinseveralAsiancountries;(ii)thecellculture
derived,inactivatedJEvaccinebasedontheBeijingP.
strain,and(iii)thecellculture-derived,liveattenuate
vaccinebasedontheSA14-14-2strainoftheJEvirus.Thmouse-brainderived,inactivatedvaccinehasbeenusesuccessfullytoreducetheincidenceofJEinanumberr
o
countries,andislikelytobeusednationallyan-
internationallyforsomemoreyears.Drawbacksoftmouse-brainvaccinearethelimiteddurationoftheinduce
protection,theneedtormultipledoses,and,inmo
although
theymaynotbenaturalhostsofJEvirus,theyact
aniquitoattractants."Horsesaretheonlydomestic
tos
sofarknownwhichshowsignsofencephalitisdue
OVinusinfection.(b)Birds:Somespeciesofbirdssucn
as
pond
herons;
attleegretsandperhapspoultryandducks
PeartobeinvolvedinthenaturalhistoryofJEVirus(D)
MOSQUITO
VECTORS
Culicine
mosquitoes,
C.vishr
inand
C.gelidusalongwithsome'anophelineshave
notablyC.tritaeniorhynchus,
been
Ctritninatedas
the
veciorsofJE.Amongthese,
nchusandvishnuihasbeenimplicatedasthe

73. LEISHMANIASIS 347
TABLE2
1heepidemiologicalprofileofVLandPKDL.casesIn
endemicstates(India-2016))
blem
statement
hmaniaoaions.The3mainforn
ofthediseaseare
SIS
isendemic
inmany
countriesintropical
ORLD
follows(3) ParticularsJharkhandWestBengalUttarPradeshBihar
oishmaniasis
(VL),alsokrnownasKala-a
VLPKDIL VL PKDL VLPKDL VLPKDL
isceral
fataorizedbyirregularDoutsoffever,weightloss,
haractetofthespleenandliver,andanaemia.Most
treatedinover
95%ofcases.Itis
Female
40%43%39.7%40.8%40%50%43%NA
proportion
<15years35%29%25%
(Child
18%37%039%NA
enlareeurinBrazil,EastAfricaandinSouth-EastAsia.
proportion)
estimatedcasesated
50,000to90,000newcasesofVLoccur
eachyear.In2018,morethan95%ofnew Source:(2)
wor
rtedtoWHOoccurredin
T0countries
:
Brazil,
cases
tedia.Kenya,Somalia,SouthSudan,Sudan,
Ethiopia,
Inald,henya,
Somal
IraqandNepal.
China,
ousleishmaniasis(CL),Isthemostcommonform
Epidemiologicaldeterminants
Agentfactors
(a)AGENTS:Theleishmaniaareintracellularparasites.
Theyinfectanddividewithinmacrophages.At
least
nineteendifferentleishmaniaparasiteshavebeenassociated
Withhumaninfection.Further,themajorityoftheseofferno
CrOSSimmunityofoneagainsttheother(6).Leishmania
donovaniisthecausativeagentofkala-azar(VL);L.tropica
15
thecausativeagentofcutaneousleishmaniasis(oriental
Sore);and,L.braziliensisisthecausativeagentofmuco-
Cutaneousleishmaniasis.Butthisdistinctionisnotabsolute
VISceralformsmayproducecutaneouslesions,and
cutaneousformsmayvisceralize(7).Thelifecycleis
completedintwoditferenthostsavertebrateandan
insect;intheformer,itoccursinanamastigoteform(called
leishmaniabodies")andinthelatterasaflagellated
promastigote.(b)RESERVOIRSOFINFECTION:Thereisa
varietyofanimalreservoirs,e.g.,dogs,jackals,foxes,
rodentsandothermammals.Indiankala-azar
isconsidered
tobeanon-zoonoticinfectionwithmanasthesole
reservoir.Thisassumptionisbasedlargelyontheabsenceof
evidence(8).
ihmaniasisandcauses
skinlesions,mainlyulcers,
onexposedpartsortneoody,leavinglife-long
seriousdisability.About95%ofCLcasesoccur
Scars
in
and
the
Americas,thewediteraneandasin,theMiddleEast
CentralAsia.In2018Over85percentofnewCLcases
urredin
8countries:Afghanistan,Algeria,Brazil,
OCcul
Colombia,lran(islamichepuonco,Pakistan,lunisia
and
SyrianArabRepublic.Itisestimatedthat
between600,000
to
I
milionnewcasesoccurworldwide
annually
3
Muco-cutaneouslesihmaniasisleadstopartialortotal
destruction
ofmucousmembranesofthe
nose,mouth
andthroat.
Over90%ofmuco-cutaneousleishmaniasis
Casesoccur
inBolivia(thePlurinationalStateof)Brazil,
EthiopladnaFeru.
Kala-azar
situationisworseningduetotheoccurrence
of
ymptomaticcases,post-kala-azardermalleishmaniasis
PKDL)
undernutrition,andkala-azar/HIVCcoinfection.
Casefatalityratehasdecreasedperhapsduetoimproved
asemanagementinendemiccountries.
Hostfactors
NDIA
(a)AGE:Kala-azarcanoccurinallagegroupsincluding
infantsbelowtheageofoneyear.InIndia,thepeakageis
5to9years(1).(b)SEX:Malesareaffectedtwiceasoftenas
females.(c)POPULATIONMOVEMENT: Movementof
population(migrants,labourers,tourists)betweenendemic
hala-azarisendemicin54districtsinBihar(33)
arkhand(4),WestBengal(11)andUttarPradesh(6)
0U130millionpopulationisatriskofthedisease.Ihe
ent
situationisshowninTable1.Whilebothcutaneous
and
ACL)andvisceral(VL)disease
occur
inIndia,
2T
1S
byfarthemostimportantleishmaniasisin
.
Kala-azarhasbeendeclaredasnotifiabledisease
nBtharandWestBengal(5).
andnon-endemiCareascanresultinthespreadofinfection.
(d)SoCIO-ECONOMICSTATUS:Kala-azarusuallystrikes
thepoorestofthepoor.Povertyincreasestheriskforkala-
azar.Poorhousinganddomesticsanitaryconditions(e.g.
lackofwastemanagement,opensewerage)mayincrease
sandflybreedingandrestingsites,
aswellastheiraccessto
humans.Sandfliesareattractedtocrowdedhousingasthese
provideagoodsourceofblood-meal.Humanbehaviour,
suchassleepingoutside
orontheground,mayincreaserisk.
Asadiseaseitmoreoftendebilitatethankills,andmakes
TABLE
1
Se
Kala-azarcasesanddeaths
inIndia(2016-2018
State 2016 2017 2018
peoplebecomedependantsonothers;(e)MALNUTRITION
DietslackingProtein-energyiron,vitaminAand
zincincreasestheriskthatanintectionwillprogresstokala-
azar(3).
(G)OCCUPATTONThediseasestronglyassociates
withoccupation.Peoplewhoworkinvariousfarming
practices,
forestry,miningandishinghave
agreatriskof
beingbittenbysandflies.(g)IMMUNITY Recoveryfrom
kala-azarandorientalsoregivesalastingimmunity.During
theactivephaseofkala-azar,there
isimpairmentofcell
mediatedimmunity,this
1sreflectedinthenegativeskin
CasesDeathsCasesDeathsCasesDeains
4,773
4,127 3.4235Nest
Bengal
Utar
Pradesh
177
156
95
110
0
752
narkhand
107
115 0
1,185
0 1,3580
0
wdia
6,245
0 5,758 0 4,380
0
SOurce:14)
ese
4hmiologicalprofileofVLand
PKDLcases
in
CstatesareasshowninTable2.
reactiontoleishmanintest.

74. EPIDEMIOLOGY OFCOMMUNICABLE DISEASES
Inviewofthechangingtrendsinleprosy,theDirector
eneralofWHOplacedthemanagementofthe
olo0a
LeprosyProgrammeundertheRegionalDirector,sEA
Consideringthatthisregionhasthehighestburdenor
aiseaseglobally.TheofficeandstaffoftheGlobalLeprosy
TOgrammemovedfromGenevatoNewDelhion
July1st2005.TheWHOhasevolvedtheGlobalStrategy
forfurtherreducingtheleprosyburdenandsustaining
eprosy
controlactivities2010-2015,andmorerecenty
lobalLeprosyStrategy2016-2020:"Acceleratingtowards
aleprosy-freeworld".
Outofthetotal1.159lakhnewases
deletedrecord,atotalof90,230caseswere
treatmentduring2018.
edonde
Epidemiologicaldeterminants
Agentfactors
(a)AGENT:LeproOsyiscausedbyM.lepra
acid-fastandoccur
in
thehumanhostbotkThe
intraco
orbundles(calledglobi).Theyhaveanaffinitu
1ocu
ate
andextracellularly.IheyocCurcharacteristicall
la
cellsandcellsotthe
retucuio-endothelialsuston
remaindormantin
varioussitesandcause
.The
bacterialloadisthenighestinthelepromatoie
The
manyas2toOlnon wereestimatedinoses,As
leproma(5).Numerousantigens(morethan201amof
detectedinM.lepraebyelectrophoretictechniouos
ofthesearesharedbythoseofpathogenicome
TheGloballeprosystrategy2016-2020:
Acceleratingtowardsaleprosy-freeworld"
TheGlobalLeprosyStrategy2016-2020:"Accelerating
towardsaleprosy-freeworld"wasreleasedinAprilZ016.
Inestrategyisbasedontheprinciplesofinitiatingaction,
ensuringaccountabilityandpromotinginclusion.Itisbuilt
around
3pillarS:tostrengthengovernmentownership,
coordinationandpartnership;tostopleprosyandits
complications;andtostopdiscriminationandpromote
inclusion.Inendorsingtheglobalstrategy,3keytargets
havebeenagreedbyallnationalprogrammes(1
zero
grade2disability(G2D)amongchildrendiagnosedwith
leprosy;(2)thereductionofnewleprosycaseswithG2Dto
casepermillionpopulationand(3)zerocountries
withlegislationallowingdiscriminationonthebasisof
leprosy(3).Earlydetectionandcompletetreatmentwith
MDTremainsthefundamentalprincipleofleprosycontrol.
pathogeniemycobacteria,e.g.,BCG,M. on
M.vaccae,M.tuberculosis,etc.MOstinterestinga
antigensisthephenolicglycolipid(PGL)whichhe
lay
specificM.lepraeantigen.Kecentyearshavewitnocc
successfultransmissionotM.lepraetosomeexperimon
animals.CurrentiylargequanuuesOIM.lepraearebe
producedbymultiplicationinthe9-bandedarmadillo
nudemouse.Despiterepeatedclaims,M.lepraehas
no
beenconclusivelyshowntogrow
inartiticialmedium(
isperhapsmainlyforthisreasonthatprogress
in
rese
haslaggedbehindthanthatofmanyotherdiseases
INDIA
(b)SOURCEOFINFECTION :Itisgenerallyagree
multibacillarycases(epromatousandbord
lepromatouscases)aretnemostimportant
sour
intectioninthecommunity.Theinapparentinfectio
LeprosyiswidelyprevalentinIndia.Althoughthedisease
ispresentthroughoutthecountry,thedistributionisuneven.
AfterintroductionofMDTinthecountry,therecorded
leprosycaseloadhascomedownfrom57.6casesper
10,000populationin1981tolessthanonecaseper
10,000populationatnationallevelinDecember2005,and
thecountryachievedthegoalofleprosyeliminationat
nationallevel.
alsosourceofinfection.Theroleofindividual
tuberculoidformsotthediseaseassourcesofinfectio
clear.Thecurrentviewisthatallpatientswith
leprosy"mustbeconsideredinfectious(7)Untl
manwasconsideredtobetheonlyhostand
so
infection.Thereisnowevidencethatnaturalintecti
M.lepraearepresentin
wildanimals,e.ga
Basedonthereportsreceivedfromthestates/UTsforthe
year2018-2019,thecurrentleprosysituationinthecountry
isasfollows(4)
Atotalof1.203lakhnewcasesweredetectedduringthe
year2018-19,whichgivesannualnewcasedetectionrate
(ANCDR)of8.69perlakhpopulation.Atotalof85,302
caseswereonrecordasonIstApril2019,givinga
prevalencerate(PR)ofO.67per10,000population.The
detailedintormationonnewleprosycasesdetectedduring
2018-19indicatestheproportionofmultibacillarycaseswas
52.28percent,proportionoffemalecaseswas38.96per
cent,childcaseproportionwas7.6percent(whichgives
thechildcaserateof0.87perlakhpopulation),3.05per
centpatientswerewithgrade-Ildisability,givingdisability
rateof2.65permillionpopulation).
34states/UTshadalreadyachievedthelevelofleprosy
eliminationi.e.PRoflessthanlcaseper10,000
population.ChhattisgarhandDadra&NagarHavelihasPR
of2-5per10,000population.
Ason31stMarch2019,514districtsoutof708have
ANCDRlessthan10perlakhpopulation,72districtshave
morethan20perlakhpopulation,andonly12districtsare
withmorethan50perlakhpopulation(ofwhich3arein
Chhattisgarh,
1inGujarat,
2inMaharashtra,
1
inDadra&
NagarHaveliand5inOdisha.Threedistrictsreported
ANCDRofmorethan90perlakhpopulation.
mangabeymonkeysandchimpanzees.It
isnotyet
leprosyinwildanimalsisathreattopublichealthi
(c)PORTALOFEXIT:Itiswidelyacceptedtha
isamajorportalofexit.Lepromatouscasesharbo
ofM.lepraeintheirnasal
mucosawhichare
whentheysneezeorblowthenose.Thebacilli
ce
throughulceratedorbrokenskinofbacteriologica
casesofleprosy(8).
(d)INFECTIVITY
:Leprosyisahighlyintec
butoflowpathogenicity(9).Itisclaimedthat
patientcanberenderednon-infectiousbytre
dapsoneforabout90days(10)orwith
3weeks(12).Localapplicationofritampie
spray)mightdestroyallthebacilliwithin8day
(e)ATTACKRATESAmonghousehoe
lepromatouscases,avaryingproportIOn
12percent
-isexpectedtoshowsigns
o
years(1l).Thisoccursdespitetreatmento
most,itnotall,caseshavingbeenine
periods,beforetreatmentissought.
Hostfactors
a)AGE
:Infectioncantakeplaceatan
upontheopportunities
forexposure
generallyrisetoapeakbetween20and

75. EPDENIOLOGY OFCOMMUNICABLE DISEASLS
specificCMIiseffectivein
eliminatSomepatients.Someleprologistspreterthete
n
of
periodtoincubationperiodbecauseofthelongdurauo
theincubation
period.
ontrokie
infectioninthebody,lesionshealn/cono
producespauci-bacillary(PB)tupeontan
deficient;thediseasespreadsuncontrProsyKnowledgeofincubationperiodofrelapsesis
Iso
Ssental,asthiswilldefinethedurationofsurveillancealter
treatment
hasbeenstopped.
multibacillary(MBeprosywithnd
involvement.Sometimes,theimmun multn
(MDTY
or
altered,eitherfollowingtreatmentonse
Pathogenesis
ofleprosy(12)
improvementotimmunologicalstatus,
inflammationofskinornervesand
other
tissuesasLeprareactionleadingtotempor
disabilities/deformities.
summarizedinFig.1.
Onsetofleprosyisinsidious.Itaffectsnerves,skinand
athogenesis
ofPema
Tneeyes,itmayalsoaffectmucosa(mouth,nose,pharynX),
testis,kidney,
leprosyvoluntary/smoothmuscles,reticulo
endothelialsystemandvascularendothelium.
Bacillienterthebodyusuallythroughrespiratorysystem.
thaslowpathogenicity,onlyasmallproportionofintected
peopledevelopsignsofthedisease.Thoughintected,
majorityofthepopulationdonotdevelopthedisease.After
enteringthebody,bacillimigratetowardstheneuraltissue
andenterSchwanncells.Bacteriacanalsobefoundin
macrophages,musclescellsandendothelialcellsofblood
Classification
Leprosyisadiseasebedevilledbyclassife
Madridclassification(18),Ridley-Joplingdn,e=
theIndianclassification(20),etc.Thesean
basedonclinical,bacteriological,
munological
histologicalstatusofpatients.
TheIndianandMadridclassificationsystemsar
widelyusedintieldleprosyprogrammes:
ne
essentiallyditferent,asthefollowingcomparisonshe
vessels.
AfterenteringSchwanncellsormacrophages,fateofthe
Dacteriumdependsontheresistanceoftheinfected
individualtowardstheorganism.Bacillistartmultiplying
slowly(about12-14daysforonebacteriumtodivideinto
two)withinthecells,getreleasedfromthedestroyedcells
andenterotherunaffectedcells.Duringthisstate,person
remainsfreetromsignsandsymptomsofleprosy.
IndianclasificationMadrid
clasification
indeterminatetype
tuberculoidtype
borderlinetype
indeterminate
tuberculoid;
Rat,
rais
borderline
lepromatouslepromatoustype
pureneuritictype
Asthebacillimultiply,bacterialloadincreasesinthe
bodyandinfectionisrecognizedbytheimmunological
system.Lymphocytesandhistiocytes(macrophages)invade
theinfectedtissue.Atthisstage,clinicalmanifestationmay
appearasinvolvementofnerveswithimpairmentof
sensationand/orskinpatch.Ifitisnotdiagnosedand
treatedintheearlystages,furtherprogressofthediseaseis
determinedbythestrengthofthepatient'simmune
TheIndianclassificationhasanadditionalform,
the
neuriticinwhichnoskinlesionsexist.
TheclassificationsystemofRidleyandJopling
dividesleprosycasesintofivegroupsaccordingto
positiononanimmuno-histologicalscale
tuberculoid
borderlinetuberculoid(BL),borderline(BB),bord
lepromatous(BL)andlepromatous(LLTheoeuri
ofleprosydoesnotfindaplaceintheRidleyand
classification.Thisclassification
can
beusedonly
wa
researchfacilitiesareavailable.
response.
Specificandeffectivecellmediatedimmunity(CMI)
providesprotectiontoapersonagainstleprosy.When
M.Leprae
Enters TransientBacillemia
Schwanncells,coolerplaces(cutaneousnerves&
peripheralnervetrunksoflimbsandface)
Strongimmunological
response
Weakimmunological
response
Nervesonly:Pureneuralleprosy
Escapefoskin:Skinlesionsappear
Lesionsmayhealspontaneously
M.LepraemultiplyinSchwanncelis
engulfedHistiocyteswandering
macop
affectsother
organs
oftheg
FIG.1
Pathogenesisofleprosy

76. LEPROSY 361clinical
classificationfor
controlprogramme
withoutcapwillbeneeded.Explaintothepersonwhatyou
care
goingtodoanddemonstrateit.Touchtheskinwiththe
potthepenlightlyandasktheindividualtopointtothe
Spottouchedwithhisindexfinger.Repeatthisprocedurea
ewtimesuntilthepatientisfamiliarandcomiortabiew
theprocedure.Nowaskthepatienttoclosehiseyes
and
epeattheprocedure(firstonthenormalskinthenoverthe
attectedarea).Whiletestinglesionsoverinaccessibleareas
Oack,buttocks)thepatientmaybeaskedtocountoneach
Ouch.Donotuseother"instruments"likepin,cottonwool,
eather,etc.Whentestingforsensation,touchtheSKin
ghtlywiththepen.Donotstroke.Thepenshouldbe
perpendiculartothesurfaceoftheskin.Donotkeepasking
the
patientwhetherhefeelsthetouch.Youmaygeet
misleadingresults.Proceedfromthenormalskinto
the
patch.Giveonlyonestimulusatatime.Varythepaceof
testing.
nnkingadiagnosiso1leprosy,one
shouldgroup
the
After
don
certaincharacteristics.
Thisis
important
tient
helps
inselectingthecorTect
combination
of
Use,
rugsforagivenpatient.
Crteriafor
classification(12)
PB(Pauci-bacillary)
MB(Multi-bacillary)
Characteristics
1-5lesiopns
Skin
lesions
peripheralnerveNonerve/onlyone
6andabove
More
thanonenerveinvolvement
nerve
involvement
Negativeatallsites
Positive
atanysite
Skinsmear
Diagnosisofleprosy(12)
ACaseofleprosyisdiagnosedbyeliciting
cardinal
signsleprosythroughSystematicclinical(andwherevereauiredbacteriological)
examination.Atleastoneofthellowingcardinal(uniqueanavery
important)
signsmust
bepresenttodiagnoseleprosy.
a
Hypo-pigmented
orreddishskinlesion(s)withdefinite
sensorydeficit:
.Involvementoftheperipheralnerves,asdemonstrated
bydefinite
thickeningwithlossof
sensationandweakness/paralysisotthecoTespondingmusclesofthe
C.Nerveexamination(12)
Resourcepersonshoulddemonstratenerveexaminatioon
fromheadtotoeandalsousevideoclips.ThecardinalSIg
1S:Involvementoftheperipheralnerves,asdemonstrated
bydetinitethickeningwithalossofsensationwithor
withoutweakness/paralysisofthecorrespondingmusclesot
the
hands,feetoreyes".Examinationofnervesinallthe
patientsisveryimportantfordiagnosis,groupingandtoor
preventionofdeformity.Thisinvolvestwoaspects
(a)palpationofthenervesforthickening.tendernessand
consistency;and(b)assessImentofnervefunction
-sensory
andmotor.ThecommonlyaffectednervesareasshowninFig.2.
hands,teetoreyes;
DemonstrationofM.leproeinthelesions.
Thefirsttwocardinalsignscanbeidentifiedbyclinicalexaminationalone,whilethethirdcanbeídentifiedbyexaminationoftheslitskinsmear.
1.CLINICAL
EXAMINATION
Clinical
examinationincludescareful
interviewofthepatienttogetdetailedhistoryandexaminationofskinand
BeforetheintroductionofMDT,mostleprosycaseswere
diagnosedbymedicalofficerorspecializedleprosyworkers,anditoftenledtodelayindiagnosisandinitiationottreatment.SincetheintroductionofMDT,marnyprocedures
havebeensimplified,sothatleprosypatientscanbedeleciedbyhealthworkersinthefield.
nerves.
a.
Casehistory
Theleprosyhistoryshouldelicitthefollowing:
Name,sex.,age(yearofbirth),address,occupationetc.;
Presentingcomplaintsandtheirduration{Apatchofaewdaysorthatwhichispresentsincebirthoranitchypatchisunlikelytobeleprosy):
Historyofrecurrence(arecurrentlesionwhich"comesandgoes"willnotbeduetoleprosy);
Facial
Median
Radial
Ulnar
Anydetormity,thetimeofitsonset,andnatureofitsprogress,
Tre
reatmenthistorytreatmenttaken,whaldrugs1orleprosyandhowlong:
Anyotherassociatedillness(jaundice,cough,swellingofhefeetatpresentorintherecent
past)
Anyotherpersoninthefamilyorclosecontactshaving
Similardiseaseorhadthediseaseandwastrealed.
Lateralpopliteal
(common
peroneal)
b.Physical
examination
Posterior
thorough
inspectionofthebodysurface(skin)tothe
entpermissible,ingoodnaturallightforthepresence
OSuggestive,ortelltaleevidenceofleprosy
tibial
tisvery
nportanttopickuptheskillofelicitingsensory
esting
the
sensationoverskin2)
FIG.2
Sitesofnerve
involvement
in patch.Alightballpointpen(withplasticbody Source
:(21)

77. 70 PIDEMIOLOGY OFCOMMUNICABIE DISEASESs
immediatecontactsofacaseofleprosy,especially
multibacillary,areknowntohaveahigherriskotdeveloDng
thediscasethancomparedtothegeneralpopulation.It1s
important,therefore,toconsiderpossibleinterventionsto
preventtheoccurrenceofleprosyamonghouseholdcontacts.
However,theremu
thatthedrug/susedforchemoprophylaxisaresafe,eftective
andcost-efficientintermsofthenumberofnewcases
prevented.
Patientsathighriskofdevelopingdisability
Peoplewiththefollowingfeaturesare
more
fit.
Kely
tydevelopleprareactionandneuritiscompared
thussubjectedtodevelopingdisability-
olhers
and
Multi-bacillaryleprosy
Pastorpresentthickened/paintui/tendernervetrun
Skinlesiononface
Adolescents,pregnancy,oldage
Any inter-currentinfection
berobusttrialevidencetodemonstrate
Onaccountoflackofconsistentresultsfromvarious
studiesusingvariousdrugs(dapsone,acedapsone,
ritampicin)itistooprematuretoadvisechemoprophylaxiSas
apublichealthmeasure.Furtherresearchisneededtouse
thisasaroutinetooltopreventtheoccurrenceofdisease
amongcontacts(41).
Stagesofinvolvementofnerve
Stage
I
StageojnerveinvolvementNerves
Decomeswollen(thickened)due,toinflammatom
responseandtender,butnolossoffunction.Th
conditionisreversibleifactionistakenearly
StageII:Stageofnervedamage
-
Alongwiththickened
andpainfulperipheralnerves,
associatedwithloss
offunction(lossofautonomiC,sensory
andmotor
functions).Thisconditionisreversibleifsuitable
actionistakenearlypreierablywithin6months
StageIII:Stageofnerve
destructionInlongstanding
caseofnerveinvolvement(usuallymore
than
oneyear)nervemaybecometibrosed,thinand
atrophic.Involvednerve
iscompletely
destroyedanditsfunctioncannotbeTecovered
VII.Disability
tisestimatedthatapproximately25percentofthe
patientswhoarenottreatedatanearlystageofdisease
developanaesthesiaand/ordeformitiesofthehandsand
feet.Asasinglediseaseentity,leprosyisoneoftheforemost
causesofdeformitiesandcrippling.
Thedeformitiesmayresultduetothediseaseprocess
(e.g.lossof
eyebrows,otherfacialdetormities),orthose
resultingfromparalysisofsomemuslcesduetodamageto
peripheralnervetrunk
e.g.claw-hand,foot-drop,
lagophthalmos),orthoseresultingfrominjuriesorinfections
tohandsandfeet(e.gscarcontracturesoffingers,
mutilationofhandsandfeet,cornealulceration).Fig.3
toanyusefuldegree
Therearetwotypesofdisabilitiesinleprosy:
1.Primary:Thesedisabilitiesoccurasaresultofnerve
damage
-e.g.lossofsensation,paralysis,showstheprocessofdisabilityinhands,feetandeyes.
dryness
2.Secondary:Theseoccurasaresultofneglected
primarydisability
-e.g.ulcer,contrachure.Nervedamage
Adisabilityisdefinedaslackofabilitytoperforman
activity.
Lossofmotor
unction
Adeformityisavisibleconsequenceof
animpairment
insidethebody.
Lossofsweat LossOfsensation
Thefindingsoftheexaminationarefirstnotedin
the
DisabilityAssessmentFormseparatelyforrightandleft
eyes
handsandfeet.Thereaftereacheye,eachhandand
eacn
footisgivenitsowngrade.Deformitiesareclassifiedino
threegrades.Thecriteriasareasfollows(12,42)
Crack njury/pressure WeaknesS
Ulcer Ulcer Contracture
Examination
ofparts
WHO Sensory Vountary
Disability1testing muscle
testing
Grades
Processofdeformityineyes
Sensation Muscle
power
R normal
Musclepower
normal
Muscle
power
weak
orparalyzed
Muscle
power
nor
Musclepowe
normal
esent
Sensation
absent
Nervedamage Hands
Sensation
absent
Lagopthalmos Cornealanaesthesia Sensation
present
Feet Sensation
Exposurekeratitis/
cornealulcer
Cornealulcer absent
SensationMuscle
power
weakorparalyze
Rlinkin
absent
VisionLid
Gap
Binking
Present
Blindness Blindness
Normal
Nolid
sap
Cannot
appresentAbsen
Eye
FIG.3
COuntTedee
fingersatcornealuice
Ometresoropacity
Processofdeformityinhands,feetandeyes
Source
:(12)

78. 372
EPIDEMOLOGY OF
COMMUNICABLE DISEASES
No.ofnewleprosycases
detectedinoneyear
Totalpopulationof
thearea(ason31stMarch)
4.EVALUATION x100,000ANCDR=
Animportantaspectofleprosycontrolistoassessthe
impactotthecontroloperationsontheendemicity
Orthe
aisease,andtocompareresultsbetweendifferenttimesana
places.Indicatorsarerequiredforsuchanevaluation.
Itis
importantthattheseindicatorscanbeeasilyusedandsatisty
thecriteriaofrepeatabilityandvalidity.Ideallytheyshould
oeconceivedandtreatedassignalsforactionby
programmemanagers(6).Therearetwomaintypesof
indicatorsinleprosycontrol.
(2)RateofnewcaseswithGrade-2disabilities
per10,00,000populationperyear
Definition:
Itistherateatwhichnewcaseswithdisah
grade2aredetectedinthedennedgeographicalpopula
ulation
area)inagivenyear.
Totalno.ofnewcases
I.Epidemiologicalindicators RNCWG2DetCcted
withGrIIdisabilit
ityx10,00,000
Totalpopulationof
thearea(ason31stMarch)
lhesearerequiredtoevaluatetheeffectivenessofthe
programme,thatistoassesstheimpactoftheactiontakenwith
regardtotheproblemreduction.Theseindicesare
(a)INCIDENCE
:
Incidenceratesareoftencalculated
separatelyforditterentsubgroupsofpopulation,
e.g.,age,sex,
frequencyofhouseholdcontact.
Itisthemostsensitiveindexof
transmissionofthedisease.
Itistheonlyindextormeasuring
theettectivenessofthemeasurestaken,1.e.,reductiono
transmission.Thustheyareusefulinmonitoringthesuccessof
acontrolprogramme.(6)PREVALENCE
:
Thisprovidesa
measureofthe"caseload"andisusefulintheplanningofthe
treatmentservices.Thecontinuedreductionintheprevalence
Couldalsogiveinformationaboutthedownwardtrendofthe
disease.Itisoftenusefultocalculateprevalenceratestor
differentsubgroups,e.g.,agesex,geographicarea.Thetact
thatleprosyisnotuniformlydistributedshouldbebornein
mindwhenthesestatisticsareinterpreted(6).
(3)Treatmentcompletionrate
Definition:
Itistherateofpatientswhocompletetheir
treatmentontimeasaproxytorcurerate.Cohortanalysis
ofPBandMBcasesaredoneseparately.
NumberofnewPBcaseswho
completedMDTin9
months
NumberofnewPBcaseswho
startedMDTinayear
PB
TCR x100
NumberotnewMBcaseswho
completedMDTin18months
NumberofnewMBcaseswho
startedMDTinayear
MBTCR= X100
4.Prevalencerate(PR)A.Mainorcoreindicatorsformonitoring
progress(41) DefinitionItisthetotalnumber
ofleprosycaseson
(1)Thenumberandrateofnewcasesdetectedper
100,000populationperyear.
record/undertreatmentper10,000populationat
agiven
pointoftimeinanarea.
(2)Rateofnewcaseswithgrade-2disabilitiesper
100,000populationperyear.
(3)Treatmentcompletion/curerate.
(4)Prevalencerate
PR=-
Totalnumberofleprosycasesonrecordx10,000
Totalpopulationofthearea
(ason31stMarch)
(Acaseofleprosyisapersonwithclinicalsignso
leprosy,whorequiresMDT)
5.ProportionofGradeIIdisabilityamongnewcases
(PG2DANC)
B.Additionalepidemiologicalindicators(12)
Proportionofgradelldisabilitiesamongnewcases
Proportionoffemalesamongnewcases
ProportionofMBamongnewcases
Proportionofchild(0-14years)amongnewcases
Childrateper1,00,000population
Scheduledcastenewcasedetectionrate
Definition:Itistheproportion(%)ofnewleprosypaten
withgradeIlIdisabilityamongtotalnewcasesdetected.
No.ofGradeIldisabledcases
Scheduledtribenewcasedetectionrate detectedinayear
lotalnewcasesdetectedinayear
PG2DANC
X10
C.Qualityofserviceindicators(12)
Patientmonthblistercalendarpackstock
AbsolutenumberotfpatientsmadeRFT
Numberofrelapsereported
Proportionofcaseswhodevelopedneworadditional
disabilityafterstartingMDI
Proportionoftreatmentdefaulters
Proportionofnewcasescorrectlydiagnosed
6.Proportionoffemaleamongnewcases(PFANO
Definition:Itistheproportion(%)of
newe
patientsamongtotalnewlydetectedcases.
Numberofnewfemalepatients
Totalno.ofnewlydetected
cases
7.ProportionofMulti-bacillary(MB)amongne
ewcase
PFANC X1
(PMBANC)
Definitions
Andicatorsandformulatobeusedfortheircalculationareindicatedbelow:
Definition:Itistheproportion(%)ofnew
patier
diagnosedasMBamongnewlydetectedcases.
(1)Annualnew
casedetection
rate(ANCDR)
Definition
It
istherateatwhichnewcases(nevertreatedbefore)are
detectedinadetinedgeographicalareablock,district)inayear(April-March)
NumberofnewMBcases
Totalno.ofnewlydetectedcase
8.Proportionofchildamongnewcases
NC)
PMBANC
Definition:proportion(%)ofnewleprosypa
14yearsofageamongnewlydetectedpatients.
ientsu

79. 373
L.EPROSY
18/4
whenthe
Missionto
Lepers(now
Leprosy
Mission)
as
toundedbyBailyat
Chamba,inthe
HimachalPradesh
The
headquartersofthis
organization
latermovedto
Purulld
west
Bengal.Sincethen,
many
voluntary
organizations
nowabout150)have
sprungupinthe
cat
mportantamongthesearethe
Hind
Kusht
NivaranSangh
ormerly
the
BritishEmpire
Leprosy
Reliet
Association)
andhi
Memorial
Leprosy
Foundation,
Sevagram,
Wardha;
erman
Leprosy
Relief
Association;the
Damien
roundation;the
DanishSavetheChildFund;andthe
more
recent
JALMAwhichwastakenoverbythe
ICMRin1975.
A
Tederationbody,
"National
Leprosy
Organization
cameinto
Deingin1965toprovideacommon
platformtodiscusstheir
problemsandsharetheir
experiences.Thecampaignagainst
eprosyinIndiais
accomplished
through
anoflicial
programme,the
National
LeprosyControl
Programme
which
wasinitiatedinthemiddleof1954.n1983,itwas
convertedintoaneradication
programme.
Numberofchildleprosy
casesdetected
X100
PCANTotalno.ofnewlydetectedleprosycases
Child
rate
(CR)per100,000population
ition
:Therateotnewchildleprosycases(0-14yrs
detected
amongnepopulanonoftheareainayear.
No.ofnewchildcases(0-14yrs)
detectedina
year
Populationofthearea
(ason31stMarch)
useofleprosy.
of
age
x100,000
CK
10.
Scheduledcaste(SC)newcasesdetectionrate
Definition:lotalnumberof
newcasesdetectedamong
the
SC
populationinagiventimeinanarea.
TotalnumberofSCcases
newlydetected
x10,000
SCNCDR
AnaccountoftheNational
LeprosyEradication
Programmeisgiveninchapter7.
TotalSCpopulationinanarea
11.
Scheduledtribe(Sl)newcasesdetectionrate
Definition:TotalnumberofnewSTcasesdetected
amongtheSIpopulationingiventimeinanarea.
TotalnumberofSTcases
References
1.WHO(2001),Weekly
EpidemiolgicalRecord,No.20,
18May,2001.
2.WHO(2000),WeeklyEpidemiologicalRecord,No.2814thJuly,2000.
3.WHO(2020),
WeeklyEpidemiologicalRecord,No.36,4thSep.,2020..
4.
Govt.ofIndia(2020),AnnualReport2019-20,MinistryofHealthand
FamilyWelfare,NewDelhi.
5.Dharmendra(1985),LeprosyVollI,SamantandCompany,Bombay-
6.WHO(1988).Techn.Rep.Ser.,No.768.
7.Job,C.K.etal(1975).Leprosy:DiagnosisandManagement,Hind
KushtNivaranSangh,NewDelhi.
8.Periaswamy,
V.(1984).Ind.J.Lepr,56,No.l(suppl).
9.WHO(1980).
AGuidetoLeprosyControl.
10.Last,J.M.ed(1980).Maxcy-Rosenau
:PublicHealthandPreventive
Medicine,11thed.,AppletonCenturyCrofts.
11.Prabhakar,M.C.etal(1984).Ind.J.Lepr,56No.
1(Suppl).
12.NLEP(2019),TrainingManualforMedicalOfficers,2019.
13.VanBraket,W.H.etal.(1992).Leprosyreview,63:231
-245.
14.WHO(2009),TransmissionofLeprosy,Internet.
15.Noordeen,S.K.(1980).In:AManualofLeprosy.R.H.Thangaraj(ed
TheLeprosyMission,NewDelhi.
16.Desikan,
K.V.(1985).Ann.Natl.Acad.Med.Sci,India,21(4)207,Th-
TimesoflIndia,NewDelhi30Jan.1991.
17.Job,
C.K.(1987).Ind.J.Lepr.,59(1)1-8.
18.InternationalLeprosyCongress,Madrid(1953).lnt.J.Lepr.,21:504
19.Ridley,D.S.andJopling,W.H.(1966).Int.J.Lepr.,34,255.
20.Chacko,C.J.G.(1980).In:AManualofLeprosy.R.H.Thangaraj(ed
TheLeprosyMission,NewDelhi.
21.NLEP(2012).DisabilityPrevention&MedicalRehabilitatio
Guidelinesforprimary,secondaryandtertiarylevetcare,June,201
22.WHO(1998),Tech.Rep.Ser.No.874.
newlydetected
STNCDK
TotalSTpopulationinana
-x10,000
12.Patientsmonthblistercalendarpack(BCP)stock
(PMBCP)
Definition:StockofBCPsinmonths,accordingtothe
numberofpatientsexpectedtobetreatedinthe
nextt
quarter.
Numberofblisterpacksofeach
categoryPB(A/C),MB(A/C)]|
No.ofcasesundertreatmentineach
PMBCP
category(PB(A/C),MB[A/C)]|
13.AbsolutenumberofpatientsmadeRFT
Definition
:Numberofpatientsreleasedfromtreatment
Curingtheyear.Thenumbershouldincludeboththenew
andtheothercasestreatedinayear.
14.Numberofrelapsesreported
Dejinition:No.ofrelapsecasesrecordedinand
eportedby)thePHC,DistrictHospitals,Medicalcolleges
andotherinstitutionsinthedistrictduringthegiventime
.
Proportionofcaseswithnewdisabilityafter
startingMDT(PCWNDASMDT)
23.Yawalkar,S..(1994).Leprosyformedicalpractitionersan
paramedicalworkers,SixthEdition,CIBA-GEIGYLtd.
24.Bryceson,A.andRoy.E.P(1979).Leprosy,2nded..Church
Livingstone.
25.VanBrakel,W.H.etal.(1992).Leprosyreview,63:231-245.
26.Bharadwaj,V.P.(985).Ann.Natl.Acad.Med.Sci,21(3)128.
27.Noussitou,FM.etal(1976).LeprosyinChildrenWHO.
28.Ramu,G.etal(1980).LeprIndia,52(3)390.
29.Bharadwaj,V.P.etal(1981).LeprIndia,53:518.
30.Sinha,S.etal(1985).Ind.J.Lepr,53:33-38.
31.Dharmendra(1982).LeprIndia,54:193.
32.Govt.ofIndia(1982).KeportoftheWorkingGroupontheEradicatie
ofLeprosy,MinistryotfiealthandfamilyWelfare,NewDelhi.
33.WHO(1982).Techn.Rep.Ser.,No.675.
34.WHOandNLEPIndia(2000),GuidetoEliminateLeprosyasaPub
HealthProblem.
35.Katochi,K.etal(1985).Ind.J.Lepr.,57(3)499.
36.WHO(2003),TheFinalPushstrategytoEliminateLeprosyasaPub-
HealthProblem,QuestionsandAnswers,2ndEd.2003.
Deinition:Proportion(%)ofcaseswhodevelopednew
ineonaldisabilityafterstarting
MDT(newdisability
esnewnervedamageornewsecondaryimpairment.
No.ofcasesdeveloped
neworadditionaldisability
duringtreatmentPCWNDASMDT
x100
6.Proportion
ofnewcasescorrectly13
No.ofcasesputunder
MDTduringtheyear
aiagnosed
(PNCCD)
FNCCD
No.of
newcasescorrectlydiagnosedx100
No.ofcasesvalidated(DNTteam
Anti-leprosy
activities
TH inIndia
oryofanti-leprosyworkinIndiagoesbackto

80. linitytreatment(TCT)
treatment
oftheeammunity,
irrespectiveofthenumberofactive
387
Total
endemic
commu
clinical
cases;
targetedtreatment
EuropeandCentralAsia,wherethenumbersofpeople
acquiringHIVinfectionanddyingfromHIV-relatedcauses
continuetoincrease.The
globalHIVepidemicduring2019
ISsummarizedinTable1.
clinical
casesandtheicontacts
(household,
school,
Asafirststepinimplemetingtheneweradication
(TTT)
treatmentofallactive
b.
Total
playmates) WHOandUNAIDShasdefineddifferenttypesofHiv
epidemics.Theyareasfollowws(3)
AS
7countrieswere
selectedfortheinitialpilot
Ireatment
stratctcampaigns.In2012itwas
implementedinBetou
Low-levelHIVepidemics
Congo.In2013,implementation
was
elledistrictsof
andttinGhana,PapuaNewGuineaandVanuatu,
achievingacoverage
implementmasstreatmentactivities(9),
AlthoughHIVmayhaveexistedformany,years.ttnas
Everspreadtosubstantiallevelsinanysub-population.
Recordedinfectionislargelyconfinedtoindividualswith
higherriskbehaviour
e.g.sex
workers,druginjectors,men
navingsexwithothermenNumericalproxyi
prevalencehasnotconsistentlyexceeded5%inanydetined
sub-population.
ofmorethan90percent.In2014,
Cameroon,Indonesia,andSolomon
Islandsareto
7.
Evaluation
ToTodeterminewhetherornotyawshasreallybeenConcentratedHIVepidemics
htundercontrol,serologicalstudiesareneeded.
HIVhasspreadrapidlyinadefinedsub-population.but
snotwell-establishedinthegeneralpopulation.This
epidemicstatesuggestsactivenetworksofriskwithinthe
sub-population.Thefuturecourseoftheepidemic
1s
determinedbythefrequencyandnatureoflinksbetween
highlyinfectedsub-populationsandthegeneralpopulation.
Numericalproxy:HIVprevalenceisconsistentlyover
5%in
atleastonedefinedsub-populationbutisbelow1%in
pregnantwomeninurbanareas.
born
sincetheyawsmasscampaignwascompleted,itwould
mean
thatthecampaignhadbeentotallysuccessful.The
ldeallifnoyawsantibodiesweretoundamongchildren
actualsampleofthepopulationtobetestedmaybeaslow
as
1or2percent.
References
WHO(1981).Wkly.Epi.Rec.,56:241-248.
2
WHO(1982).TheWorkofWHO,1980-81.
WHO(1982).Techn.Rep.Ser,674
4Wasley,G.D.(1980).MiddleEastHealth,4(7)33.
Chulay,J.D.(1979).PrinciplesandPracticeofInfectiousDiseases,
Mandell,G.L.etal(eds),JohnWiley,NewYork.
6
WHO(2016),YawsFactsheet,June2016.
7.WHO(1968).TheSecondTenYearsoftheWHO,1958-1967
8.Hopkins,D.R.(1976).Am.J.Trop.Med&Hyg.,25:860.
9
WHO(2014),FactSheet,No.316,Feb.2,2014.
GeneralizedHIVepidemics
Ingeneralizedepidemics,HIVisfirmlyestablishedinthe
generalpopulation.Althoughsub-populationsathighrisk
maycontributedisproportionatelytothespreadofHIV,
sexualnetworkinginthegeneralpopulationissufficientto
Sustainanepidemicindependentofsub-populationsat
higherriskofinfection.NumericalproxyHIVprevalence
consistentlyover1%inpregnantwomen.
AIDS OnthevergeoffourthdecadeoftheAIDSepidemic,the
worldhasturnedthecornerithashaltedandbegunto
reversethespreadofHIV.Thequestionremainshowquickly
AIDS,theacquiredimmuno-deficiencysyndrome
sometimescalled"slimdisease")isafatalillnesscausedby
aretrovirusknownasthehumanimmuno-deficiencyvirus
(HIV)whichbreaksdownthebody'simmunesystem,
leavingthevictimvulnerabletoahostoflife-threatening
opportunisticinfections,neurologicaldisorders,orunusual
malignancies(1).AmongthespecialfeaturesofHIV
infectionarethatonceinfected,itisprobablethataperson
willbeinfectedforlife.Strictlyspeaking,theterm
AIDDS
relersonlytothelaststageoftheHIVinfection.AIDScanbe
calledourmodernpandemic,affectingbothindustrialized
anddevelopingcountries.
theresponsecanchartanewcoursetowardsvisionzero
discrimination,zero
AIDS-relateddeathsthroughuniversalaccesstoeffective
HIVprevention,treatment,careandsupport.
newHIVinfectionandzero
HIVincidence(thenumberofnewHIVinfectionsina
populationperyear)isthekeyparameterthatprevention
effortsaimtoreduce,sincenewlyintectedpersons
contributetothetotalnumberofpersonslivingwithHIV;
theywillprogresstodiseaseanddeathovertime;andarea
potentialsourceoffurthertransmission.Since1997,the
yearinwhichannualnewinfectionspeakedto3.2million
casesglobally,thenumberofnewinfectionshasfallento1.7
millionin2019.ThisreductioninHIVincidencereflects
naturaltrendofepidemic,aswellastheresultofprevention
programmesresultinginbehaviouralchangesindifferent
contexts,likechangesinsexualbehavior;programmes
targetingkey
programmesforpeoplewhoinjectdrugs;maximizingthe
Problemstatement
WORLD
ecognizedasanemergingdiseaseonlyintheearly
oUs,
AlDShasrapidlyestablisheditselfthroughoutthe
OTId,andislikelytoendureandpersistwellintothe2lst
rg.
AlIDShasevolvedfromamysteriousillnesstoapreventionbenents
otAkvs,includingforthepreventionof
S0alpandemicwhichhasinfectedtensofmillionspeople.
populationssuchasharm-reducing
mother-to-childtransmissionofHlV;andvoluntarymedical
malecircumcisioninhighHlV-prevalencesettings(4).
sing
developmenthavebeenseeninrecentyearsin
ettorts
toaddresstheAIDSepidemic,including
eased
accesstoeffective
treatmentandprevention
HIammes.However,thenumberofpeoplelivingwitn
AIDSdes
togrow,asdoesthenumberofdeathsdueto
particularconcernaretrendsaffectingEastern
Womenrepresentabouthalfofallpeoplelivingwith
HIVworldwide,andmorethanhalf(about60percent)in
sub-SaharanAfrica.HIVistheleadingcauseofdeath
amongwomeninreproductiveage.Genderinequalities,
differentialaccesstoservicesandsexualviolenceincrease

81. 388 EPIDEMIOLOGY OFCOMMUNICABILE DISEASES
TABLE
1
Global
H1IVstatistics(2019)
Peopleliving
withHIV
In2019,therewere38.0million(31.6million-44.5million)peoplelivingwithHIV.
36.2million(30.2million-42.5million)adults.
1.8
million(1.3million-2.2million)children(0-14years).
81%(68-95%)ofallpeoplelivingwithHIVknewtheirHIVstatus.
About
7.1millionpeopledidnotknowthattheywerelivingwithHIV.
75.7million(55.9milion-100million)peoplehavebecomeinfectedwithHIVsincethestartofth
Peoplelivingwith
HIVaccessing
AsoftheendofJune2020,26.0million(25.1million-26.2million)peoplewere
accessing
antiretr
In2019,25.4million(24.5million-25.6million)peoplewereaccessingantiretroviraltherapy,upfromather
(5.9million-6.4million)in2009.
-In2019,67%(54-79%)ofallpeoplelivingwithHIVwereaccessingtreatment.
68%(54-80%)ofadultsaged15yearsandolderliVingwitnivhadaccesstotreatment,asdid5eo
ofchildrenaged0-14years.
73%(60-86%)offemaleadultsaged15yearsandolderhadaccesstotreatment;however,just61
la0
ofmaleadultsaged15yearsandolderhadaccess.
-85%(63-100%)ofpregnantwomenlivingwithHIVhadaccesstoantiretroviralmedicinesto
preventhran.
ofHIVtotheirchildin2019.
antiretroviral m6.4
mlli
therapy
%136-6%
(48-14%
NewHiV
Since
2010,newHIVinfectionshavedeclinedby23%,from2.1million(1.6million-2.9million)to1.7
mil
(1.2million-2.2million)in2019.
Since
2010,newHIVinfectionsamongchildrenhavedeclinedby52%,from3,10,000(2,00,000-5.00.00
in2010to1,50,000(94,000-2,40,000)in2019.
infections
00.00)
AlDS-related -AIDS-relateddeathshavebeenreducedby60%sincethepeakin2004.
In2019,around6,90,000(5,00,000-9,70,000)peoplediedfromAIDS-relatedillnessesworldwide,
compared
1.7million(1.2million-2.4million)peoplein2004and1.1million(8,30,000-1.6million)peoplein2010
-AIDS-relatedmortalityhasdeclinedby39%since2010.
deaths
Women Womenandgirlsaccountedforabout48%ofalnewHIVinfectionsin2019.Insub-SaharanAfrica,womenand
girlsaccountedfor59%ofallnewHIVinfections,fiveinsixnewinfectionsamongadolescentsaged15-19years
areamonggirls.Youngwomenaged15-24yearsaretwiceaslikelytobelivingwithHiVthanmen.
Insomeregions,womenwhohaveexperiencedphysicalorsexualintimatepartnerviolenceare1.times
more
likelytoacquireHIVthanwomenwhohavenotexperiencedsuchviolence.
-In2019,81%(68-95%)ofpeoplelivingwithHIVknewtheirHIVstatus.
Amongpeoplewhoknewtheirstatus,82%(66-97%)wereaccessingtreatment.
Andamongpeopleaccessingtreatment,88%(71-100%)werevirallysuppressed.
90-90-90
Keypopulations Keypopulationsandtheirsexualpartnersaccountfor:
62%ofnewHIVinfectionsglobally
-99%ofnewHIVinfectionsineasternEuropeandcentralAsia.
-97%
ofnewHIVintectionsintheMiddleEastandNorthAfrica.
-96%ofnewHIvinfectionsinwesternandcentralEuropeandNorthAmerica.triet
-98%ofnewHIVinfectionsinAsiaandthePacific.
-.77%
oftnewHlvintectionsinLatinAmerica.
-69%ofnewHIVinfectionsinwesternandcentralAfrica.
-60%ofnewHIVinfectionsintheCaribbean.
-28%ofnewHIVinfectionsineasternandsouthernAfrica.
TheriskofacquiringHIVis:
-26timeshigheramonggaymenandothermenwhohavesexwithmen.
-29timeshigheramongpeoplewhoinjectdrugs.
-30timeshigherforsexworkers.
-13timeshigherfortransgenderpeople.
inthree
TBremainstheleadingcauseofdeathamongpeoplelivingwithHIV,accountingforaround
one
AIDS-relateddeaths.
In2018,anestimated10.0million(9.0million-11.1million)peopledevelopedTBdisease,appr
whomwerelivingwithHIV.
.PeoplelivingwithHIVwithnoTBsymptomsneedTBpreventativetherapy,whichlessensthe
TBandreducesTB/HIVdeathratesbyaround40%.
.1.8millionpeoplelivingwithHIVacross65countriesstartedpreventivetreatmentfor15therefore
nol
Itisestimatedthat44%ofpeoplelivingwithHIVandTBareunawareoftheircoinfectionand
receivingcare
HIV/tuberculosis
ped18
disease,
approximately95
iskof
developins
(TB
018
Source:(2)
bold
call
to
action
women's
vulnerabilitytoHIV,and
women,especiallu
youngerwomen,areDIologicallymoresusceptibletoto
HIV(5).
togetonthe"Fast-Track"and
reacn
POple
agenda
beng
behind.Thestrategyfocusesonthe
untinis
TheUNAIDS2016-2021
strategyis
a
enda.
IIs

82. -90-90treatment
targets,
toclosethe
AIDS389
call
toreachthe
testingsle
for90percentofthepeoplewithHIV
being
H
ftheirinfection,90percentofpeopleawarethathave
HIVinitiatingARIand90percentofthose
he d
ARThavingundetectable
levelsofHIV
intheirh 2020.Milestonetargetsalsoincludea75percentblooninnewinfectionbetween2010and2020,andingannualHIV-related
deathstolessthan500,000by
-
a
call
andtoprotectthehealthofthepeoplelivingwith
followedbyAndhraPradesh3.14lakh,Karnataka2.69lakh,
UttarPradesh1.61lakh,Telangana1.58lakhetc.There
wereanestimated69.22thousandnewcasesinthecountry
in2019.Maharashtrawasestimatedtohavethehighest
numberofnewHIVinfections(8.54thousand),followedby
Bihar(8.04thousand),UttarPradesh(6.72thousand),West
Bengal(3.97thousand)andGujarat(3.37thousand)cases.
In2019,therewere58.96thousandAIDSrelateddeaths
inthecountry.AndhraPradeshwasestimatedtohavethe
highestnumberofAIDSdeaths(11.43thousand)in2019,
tollowedbyMaharasthra9.69thousand,Karnataka
6.39thousand,Telangana4.08thousandandUttarPradesh
3.87thousand(8).
2020globally(6).
TheSustainableDevelopmentGoaltargetistoendtheDSepidemicby2030.UNAIDShasledthedevelopment
fa
globalstrategy,
"tastIrack:EndingtheAIDSEpidemic
2030,whilemoredetailed,sectoralstrategysuchasheWHOsectorstrategyonHIV2016-2021aremderdevelopment.Themainareasoffocuspost-2015
nclude(4):
A
focusonpopulationleftbehindbytheHIVresponse,
suchasadolescentgirls,keypopulation(sexworkers,menwhohavesexwithmen,peoplewhoinjectdrugsand
transgenderpeople),migrantsandchildren;
AfocusonlocationswherethegreatestHIV
transmission
is
occurringandwiththegreatestHIVburden,andthe
useofdatatosupporttheimpactofprogrammes;
KeypopulationaffectedinIndia
TheHIVepidemicinIndiaisdrivenbysexualtransmission,
whichaccountsfor86percentofnewinfectionsin2017.
Itisfollowedbyparent-to-child,injectingdrugusers,
homosexualsandbloodandbloodproductsuseetc.
AccordingtoHIVsentinelsurveillanceduring2016-
2017,theoverallHIVprevalenceamongANCclinic
attendees(consideredasproxyforprevalenceamong
generalpopulation)continuestobelowat0.29percent,
withanoveralldecliningtrendatnationallevel.India
continuestoportrayaconcentratedepidemic.HIV
prevalenceamongdifferentriskgroupsisasshowninFig.1.
AnintegratedHIVresponsethat
contributiontowardsuniversalhealthcare,including
healthworkforce,procurementsystems,injectionand
bloodsafety,andtreatmentofcoinfections;and
expandsthe
SexworkersandHIV(FSW):In2017,anestimated
1.6percentoffemalesexworkersinIndiawerelivingwith
HIV,althoughthisfigurevariesbetweenstates.Forexample,
prevalenceamongFSWisestimatedat7.4percentin
Maharashtraand6.3percentinAndhraPradesh.Stigma
anddiscriminationagainstsexworkersrestricttheiraccessto
healthcare.NACOreportedreaching77.4percentofsex
workerswithHIVpreventionactivitiesintheyear2015.
Intheyear2017,around67percentofHIVpositive
sexworkerswereawareoftheirstatusand91percentof
sexworkers(HIVpositiveandnegative)reportedusing
condom(9).
Sustainableprogrammeswithtransitioningtodomestic
fundingofessentialHIVservices.
TheinteractionofHIV/AIDSwithotherinfectious
iseasesisan
uberculosis,bacterialinfectionandmalariahavebeen
dentifiedastheleadingcauseofHIV-relatedmorbidityin
üb-SaharanAfrica.HIVinfectionincreasestheincidence
ndseverityofclinicalmalariainadults(7).
ThenationalHIVstrategicplansinmostSEARcountries
ccordprioritytoprevention,careand
nterventionstohigh-riskpopulations;howevercoverageof
comprehensivepackageofHIVinterventionsforsex
orkers,menhavingsexwithmen,transgenderpersonsand
jectingdrugusersremainslowinallcountries.
increasingpublichealthconcern.
PeoplewhoinjectdrugsandHIV:'PrevalenceofHIV
amonginjectingdrugusers(IDU)ishighandmajorrouteof
HIVtransmissioninIndia'snorth-easternstates.In2016,
1.7millionpeopleinIndiawereestimatedtobeinjecting
drugusers.In2017,6.3percentofpeoplewhoinjectdrugs
werethoughttobelivingwithHIV,ofwhomhalfwere
awareoftheirstatus.Prevalencevarieswithstatese.g.,
treatment
NDIA
2
Nowintoitsfourthdecade,India'sepidemicismarkedby
eterogeneity-notasingleepidemicbutmadeupofanumber
distinctepidemics,insomeplaceswithinthesamestate.
Theestimatedadult(15-49years)HIVprevalencetrend
as
beendeclininginIndiasincetheepidemic'speakinthe
2ar2000andhasbeenstabilizing.Theestimate
ar2019was0.22percent(0.24percentamongadult
alesand0.20percentforfemales).Atthesub-national
vel,threestateswiththehighestadultHIVprevalenceare
mthenorth-easternpartofthecountry,namelyMizoram
per.cent,Nagaland1.45percent,andManipur
8percent.Otherhighadultprevalenceratestatesare
dhraPradesh0.69
per
cent,Meghalaya0.54percent,
iangana0.49percent,Karnataka0.47percent,
.41
percent,Maharashtra0.36percentetc.
tionally,therewereanestimated23.48lakh
98lakh-30.98lakh)PLHIVin2019,Maharashtrawas
atedtohavethehighestnumberofPLHIV(8.96lakh),
ANC-0.28A
MigrantS-0.2lt
2
FSW-1.6
the Truckers-h0.2
MSM
2.7
TG-
IDU
3.1
b.3
2 4
6 10 12
HIVPrevalence(%)
FIG.1
HIVprevalenceforANCattendeesandamong
differenthighriskgroups,India,2017
Source:(9,10)

83. 396 EPIDEMIOLOGY OFCOMMUNICABLE: DISEASES
hospitalsandclinics.Pre-sterilizeddisposables
needlesshouldbe
usedastaraspossible.Oneshom and
injectionsunlesstheyareabsOlutelynecessary,dvoid
1.Prevention syring
(a)EDUCATION
UntilavacineorcureforAlDSisfound,theonlymeans
atpresentavailableishealtheducationtoenablepeopleto
makelite-savingchoices(e.g.,avoidingindiscriminatesex,
usingcondoms).Thereis,however,noguaranteethatthe
useofcondomswillgivefullprotection.Oneshouldalso
avoidtheuseofsharedrazorsandtoothbrushes.
ntravenousdrugusersshouldbeinformedthatthesharing
ofneedlesandsyringesinvolvesspecialrisk.Women
sufteringfromAIDSorwhoareathighriskofinfection
shouldavoidbecomingpregnant,sinceinfectioncanbe
transmittedtotheunbornornewborn.Educationalmaterial
andguidelinesforpreventionshouldbemadewidely
available.Allmassmediachannelsshouldbeinvolvedin
educatingthepeopleonAlDS,itsnature,transmissionand
prevention;thisincludesinternationaltravellers.
2.Antiretroviraltreatment
AtpresentthereisnovacCineorcurefortreatrma.
HIVinfection/AlDS.However,thedevelopmonnentO
thatsuppresstheHV
intectionitselfratherthadgs
complicationshasbeenimportantdevelopment.
TL
antiviralchemotherapyhaveprovedtobe
use
prolongingthelifeofseverelyillpatients.
TheavailabilityotagentsincombinationsuppressH
replication.Ithasaproloundimpactonthenaturalhisto
ofHIVinfection.Patientswno
achieveexcellentsuppressin
ofHIVgenerallyhavestabil2ationor
improvementofthei
clinicalcoursewhichresultsirompartialimmunoloci
reconstitutionandasubsequentdecreaseincomplication
ofimmunosuppression.Conceptaboutthetiming.of
Such
therapyhavechangedconsiderably.
(b)COMBINATION HIVPREVENTION(22)
CombinationpreventionprogrammesuseamixofClassificationofdrugsusedforART(18)
biomedical,behaviouralandstructuralinterventionstomeet
the
currentHIVpreventionneedsofparticularindividuals
andcommunitiessoastohavethegreatestpossibleimpact
onreducingnewinfections.
ThedrugsusedforARTareclassifiedas:
ARVdrugsplayakeyroleinHIVprevention.People
takingARTwhoachieveoptimalviralsuppressionare
extremelyunlikelytopassHIVtosexualpartners.ARVdrugs
takenbypeoplewithoutHIVasPrEPorPEParehighly
ettectiveinpreventingHIVacquisition.
Nucleosidereversetranscriptaseinhibitors(NRTIs)
Abacavir(ABC)
Didanosine(ddl)
Emtricitabine(FTC)
Lamivudine(31C),
Stavudine(d4l)
Zidovudine(AZT)
Nucleotidereversetranscriptaseinhibitors(NtRTs)
OtherbiomedicalinterventionsthatreduceHIVrisk
practicesand/ortheprobabilityofHivtransmissionper
contacteventincludethefollowing:
Tenofovir(TDF)
Non-nucleosidereveresetranscriptaseinhibitors
(NNRTls)
Efavirenz(EFV)
Etravirine(ETV)
Nevirapine(NVP)
Male andfemalecondomsandcondomcompatible
lubricant
:malecondomsareestimatedtoreducee
heterosexualtransmissionbyatleast80%andtooffer
64%protectioninanalsexamongmenwhohavesexwith
men,ifusedconsistentlyandcorrectly.Fewerdataare
availablefortheefficacyoffemalecondoms,butevidence
suggeststheycanhaveasimilarpreventioneffect.
Needleandsyringeprogrammesarehighlyassociatedwith
areductioninHIVtransmissionthroughinjectingdruguse.
Proteaseinhibitors(Pls)
Atazanavir+ritonavir
(ATV/r)
Darunavir+ritonavir(DRV)r)
ros-amprenavir
+ritonavir(FPV/r) S
Indinavir+ritonavir(IDV/r)
Lopinavir/ritonavir(LPV/)
Saquinavir
+ritonavir(SQV/r)
Integrasestrandtransferinhibitors(INSTIS)
Opioidsubstitutiontherapywithmethadoneor
buprenorphineisthemosteffectiveformoftreatmentfor
opioiddependenceandhastheadditionalbenefitof
effectivelyreducingHIVriskbehaviourandtransmission
throughinjectingdruguse.Opioidsubstitutiontherapy
alsoprovidesadherencesupporttopeopleonART.
Voluntarymedicalmale
circumcision(VMMC):three
randomizedclinicaltrialsinAfricademonstratedan
approximately60%reductionintheriskoffemale-to-
malesexualtransmission.Forhigh-burdensettings,joint
programmeofWHOandUnitedNationsonHIV/AIDS
(UNAIDS)recommendedtheinclusionofVMMCasan
additionalimportantstrategytorpreventionof
heterosexuallyacquiredHIVintectioninmen.
Raltegravir(RAL)
Dolutegravir(DTG)
Fusioninhibitors
Enfuvirtide(T-20,Fuzeon)
WHOrecommendedARVtreatmentschedule
HIVcanbesuppressedbytreatmentregimens
posed
Oyacombinationof3ormoreARVdrugs.Gurrent
doesnotcureHIVinfection,buthighlysuppr
ls
replicationwithinaperson'sbodyandallowsan
inaih
immunesystemrecoverytostrengthenga9016WHO
capacitytofightoffinfections.Since20o
recommendedthatallpeoplelivingwithHIVEbePa
withlifelongART,includingchildrenadoardles
adults,andpregnantandbreast-feedingwon
ofclinicalstatusorCD4cellcount.
(c)PREVENTIONOFBLOOD-BORNE
HIVv
TRANSMISSION
Peopleinhigh-riskgroupsshouldbeurgedtorefrain
fromdonatingblood,bodyorgans,Sperm
orothertissues.
Allbloodshouldbescreenedfor
HIV
1&HIV2before
transfusion.Transmissionofinfectiontohaemophiliacscan
bereducedbyintroducingheattreatmentoffactorsVIII
andIX.Strictsterilizationpracticesshouldbeensuredin
ne
currentHIVtreatmentguidelinesincluder
fales
optionswithbettertolerability,higheretticacynreviou
oftreatmentdiscontinuationwhencompareanwnded
th=
recommendedmedicines.In2019,WHO
mmend

84. Ese
of
dolutegravir-baseorlow-doseefavirenzforfirst-line
TB
chnTGshouldalsobeusedinsecond-linetherapy,ifnot
397
second-linetherapy(23).EFV400mgisrecommendedasan
alternativedrug,withEFV600mgmaintainedasanoptionfor
Specialsituations.RALisrecommendedforneonatesandcan
beconsideredasanalternative
ifLPV/rsolidformulationsare
notavailableforchildrenweighinglessthan20kgbody
weight(24).Table4and5showstherecommendedfirst-line
andsecond-lineARTregimens.
therapy
foreveryonelivingwithHIVincludingadults,
womenandadolescentgirlsof
childrenandpeoplecoinfectedwith
pregnantWomen.
child-bearmgpotential.
edinfirsi-lineanddarunavir/ritonavirisrecommendedas
theanchordruginthird-lineorasanalternativeoption
TABLE4
Preferredandalternativefirst-lineARTregimens
Preferredfirst-lineregimenPopulation Alternativefirst-lineregimenSpecialcircumstances
-
TDF+3TC(orFTC)+EFV600mg
AZT+3TC+EFV600
mg"
TDF+3TC(orFTC)+PI/r"
TDF+3TC(orFTC)+RAL
TAF+3TC(orFTC)+DTG
ABC+3TC+DTG*
AdultsandadoescentsTDF+3TC(orFTC)+DTG* TDF+3TC+EFV400
mg
ABC+3TC+EFV(orNVP)
AZT+3TC+EFVa(orNVP)
AZT+3TC+LPV/r(orRAL)
ABC+3TC
+DTG4 ABC+3TC+LPV/r
ABC+3TC+RAL"
TAF+3TC(orFTC)+DTG
Children
Neonates AZT+3TC+RAL AZT+3TC+NVP AZT+3TC+LPV/r
STC:lamivudine;ABC:
abacavir,AZT:zidovudine;DTG:dolutegravir,EFV:efavirene,FTC:emtricitabine;
LPV/r:lopinavirhritonavir,NVPnevirapine,
Pir
proteaseinhibitorboostedwithritonavir;
RAL:
raltegravir;
TAF:tenofoviralafenamide;TDF:tenofovirdisoproxilfumarate
Efective
contraceptionshouldbeofferedtoadult
women
andadolescentgirlsofchildbearingage
or
potential.DTGcan
beprescribedforaduooe
andadolescentgiris
orchildbearingageorpotentialwhowishtobecomepregnantorwhoarenototherwiseusingoraccessingconsistentandetfectivee
contraceptioniftheyhavebeentullyinformedofthepotentialincreaseintheriskofneuraltubedefects(atconceptionanduntiltheendofthetirst
trimester).Ifwomenidentitypregnancyafterthefirsttrimester,DTGshouldbeinitiatedorcontinuedforthedurationofthepregnancy.
EFV-basedARTshouldnotbeusedinsettingswithnationalestimatesofpretreatmentresistancetoEFVof10%orhigher.DTG-basedARTispreferred,
andifDTGisunavailable,
aboosted
Pl-based
regimenshouldbeused.Thechoiceof
PVrdependsonprogrammaticcharacteristics.
TAF
may
beconsideredforpeoplewithestablishedosteoporosisand/orimpairedkidneyfunction.
For
ageandweighgroupswithapprovedDTGdosing.
RAL
shouldbeusedasanalternativeregimenonlyifLPV/tsolidformulationsarenotavailable
ForageandweightgroupswithapprovedTAFdosing.
EFVshouldnotbeusedforchildrenyoungerthanthreeyearsof
age.
Neonates
startingARTwithan
RAL-basedregimenshouldtransitiontoanLPVrsolidformulationassoonaspossible.
LPV/rsyruporgranulescanbeusedifstartingaftertwoweeksofage.
TABLE5
Preferredandalternativesecond-lineARTregimens
Population Failingfirst-lineregimen Preferredsecond-lineregimen Alternativesecond-lineregimens
AZT+3TC+DRV/rd
AZT+3TC+ATV/r(orLPV/rorDRV/)4
AZT+3TC+ATV/r(orLPV/r)
TDF+3TC(orFTC)+DTG
TDF+3TC(orFTC)+EFV
(orNVP)
AZT+3TC+DTG*
Adultsand
adolescents
AZT+3TC+EFV(orNVP) TDF+3TC(orFTC)+DTG TDF+3TC(orFTC)+ATV/r
(orLPV/ror
DRV/Æ)d
ABC+3TC+DTG AZT+3TC+LPV/(orATV/) AZT+3TC+DRV/rs
AZT(orABC)+3TC+DTG
AZT(orABC)+3TC+DTG
AZT(orABC)+3TC+RAL
AZT(orABC)+3TC+LPV/(orATV/)
ABC+3TC+LPV/(orATV/or
DRV/9)|
Childrenandinfants
ABC(orAZT)+3TC+LPV/r
ABC(orAZT)+3TC+EFV
ABC+3TC+DTG*
AZT+3TC+NVP
3TC:lamivudine;ABC:abacavir;ATV/r:atazanavir/ritonavir;
AZT:zidovudine;DRV/r:darunavir/ritonavir;DTG:dolutegravir;EFV:efavirenz:
FIC:emtricitabine;LPV/r:lopinavir/ritonavir;NVP:nevirapine;RAL:raltegravir;TDF:tenofovirdisoproxilfumarate.
SequencingifPlsareusedinfirst-lineART:ATV/r(orLPV/r.
AZT+3TC+DTGinsecond-lineART.
Efectivecontraceptionshouldbeoffered
toadultwomenandadolescentgirsofchildbearingageorpotential.DTGcanbeprescribedforadultwomen
andadolescentgirlsofchildbearingageorpotentialwhowishtobecomepregnantorwhoarenototherwiseusingoraccessingconsistentandeffective
Contraceptioniftheyhavebeenfullyinformedofthepotentialincreaseintheriskofneuraltubedetects(atconceptionanduntiltheendofthefirst
trimester).Ifwomenidentifypregnancyafterthefirsttrimester,DTGshouldbeinitiatedorcontinuedforthedurationofthepregnancy.
AF(tenofoviralafenamide)canbeusedasanalternativeNRTIinspecialsituationsforadultsandadolescents.
AL+LPV/rcanbeusedasanalternativesecond-lineARTregimenforadulisandadolescents.
he
EuropeanMedicinesAgencycurrentlyonlyapprovesDiGtorchildrenweighingatleastl5
kgandmorewidelyforchildrenweighingmorethan
20kgwho
cantakeadult50
mg
film-coatedtablets.Studiesareongoingtodeterminedosingforyoungerchildren.withapprovalwhichwas
expected
inearly2020,butthe2016WHOrecommendationsforsecond-lineARTstillhold(Plbasedforchildre
n
forwhomNNRTishavefailedand
RALfor
childrenforwhomLPV/Ihasfailed).TAF(tenofoviralafenamide)canbeusedasanalternativeNRTIinchildrenweighingatleast25kg.
ATVIrcanbeusedasanalternativetoLPV/s
forchildrenoiderthanthreemonths.butthelimitedavalabilityofsuitableformulationsforchildren
youngerthansixyeat,thelackof
afixed-doseformulationandtheneedforseparateadministrationoftheritonavirboostershouldbeconsideredwhen
Choosing
thisregimen.
DRV/dependingonprogrammaticconsiderations)+TDF+3TC(orFTC)andthen
DRVshouldnotbeusedforchildrenyoungerthanthreeyearsandshouldbecombinedwithappropriatedosingofritonavir.

85. EPIDEMIOLOGY OFCOMMUNiCABLE DISEASES
whocannottolerateorarecontraindicate
Morethan
1millionpeoplelivingwithHIv NRTI
programmesshouldplancarefullytoensurethat
DIGsupplyisavailabletomeettheanticipateddemand;a
phasedapproachtoimplementationisrecommended.
everalcountrieshaveadoptedapproachestostart
transitioningtoDTGamongpeoplereceivingfirst-lineART
are
currently
and7showthetransitionotpeoplewhoarestablo
toaDTG-basedregimen.
usingDTGinlowandmiddle-inc
countries
able
6
oare
stable
onART
TABLE6
ConsiderationsfortransitiontoTDF+3TC+DTGamongadultsandadolescents
Treatmenttransitionscenario Preferredapproach Comments
DTGforpeoplelivingwithHIVinitiatingART
Adultsandadolescents Potentialriskofneuraltubedefectsamong
infants
exposedtoDTGduringtheconceptionperiod
Womennotusingor
accessingcontraceptionorwho
InitiateTDF+3TC+DTG
wanttobepregnantcanuseDTGorEFVbasedon
informedchoiceoftherisksandbenetitsofeachregimen
Pregnantandbreast-feedingwomen
InitiateTDF+3TC+DTG
TBcoinfection InitiateTDF+3TC+DTG
(DTGdoseadjustmentneeded)
Possibilityofconceptionduringbreast-feedingremains
DTG50mgtwicedailyifrifampicinisbeingusedas
the
anti-TBregimen
DTGforpeoplelivingwithHIValreadyusingafirst-lineARTregimen
Clinicalorimmunefailureor
viralloadnotsuppressed
-NoevidencetosupporttheefficacyofDTGwhenused
in
combinationwithaninactiveNRTIbackbone
Provideadherencesupport
Substitutionshouldbeconsideredinthecontextofdrug
supplyandpatientchoice
Substitutionmayconternewside-effectsandinterfere
withadherence
SwitchtoAZT+3TC+DTG
orPl/r
SubstitutiontoTDF
+3TC+DTG
maybeconsideredaccordingto
nafionalrecommendations
Viralloadsupressed
DTGregimensmaybemoredurableinthelongterm
NoevidencetosupporttheefficacyofDTGwhenusedin
combinationwithaninactiveNRTIbackbone
provideadherencesupport
Clinicallyandimmunologically
stablesandviralloadunknown
Giveprioritytoviralloadtesting
orconsiderotherprogrammatic
orclinicalindicationsindications
forsubstitutiontoDTGbasedART
Stabletonsuboptimalfirst-line
ARTregimens
SubstitutetoTDF+3TC+DTG Substitutionmayconfer
newside-effects.
Provideadherencesupport
3TC:lamivudine:AZT:zidovudine:DTG:dolutegravir;EFV:efavirenz;NRTI:nucleosidereverse-transcriptaseinhibitor
Plr:
proteaseinhibitorboostedwithritonavir;TDF:tenofovirdisoproxilfumarate;TB:tuberculosis.
Efectivecontraceptionshouldbe
offered
to
adultwomenandadolescentgirlsofchild-bearingageorpotential.DTGcanbeprescribedforadultwomenand
adolescentgirlsofchild-beringageorpotentialwhowishtobecomepregnantorwhoarenototherwiseusingoraccessingconsistentandeffective
contracaptionittheyhavebeenfullyinformedofthepotentialincreaseintheriskofneuraltubedefects(atconceptionanduntiltheendofthefirsttrimester).
f
womenidentifypregnancyafterthefirsttrimester,DTGshouldbeinitiatedorcontinuedforthedurationofthepregnancy.
After
adherencecheckandpersistentdetectableviralload.
Definedasstablebasedonnationalguidelines.
Source:(24)
TABLE7
ConsiderationsfortransitiontooptimalARTregimensforchildren
whoareconsideredstableonARTbasedonnationalguidelines
Currentregimen WeightOptimalregimenfortransitionConsiderations
<20kg lfstable,childrencanbetransitionedtoDTGwhentheyreach20kg
Ifstable,childrencanbetransitionedtoTDF+3TC+DTGWhen
theyreach30kg
ABC+3TC+LPV/r
AZT+3TC+NVP
20-30kgABC+3TC+DTG
AZT3TC+EFV
ABC+3TC+NVP
30kgTDF+3TC+DTG
<20kgNochangeuntiltheyreach20kgTransitiontooptimalregimensforthesechildrenisofvalue
they
unlesstreatmentfailureoccursreach20kgandDTGcanbeusedmaintainingonce-dallyadminis
Ifstable,childrencanbetransitionedtoTDF+3TCDTG
when
theyreach30kg
ABC+3TC+EFV20-30
kgABC+3TC+DTG
30
kgTDF+3TC+DTG
<20kgNochangeuntiltheyreach20kgEnsuretheuseoftabletsassoonaspossibletoreduce.pillburaen
unlesstreatmentfailureoccurs
ABC+3TC+LPV/
AZT+3TC+LPV/r90.
ransitionfromAZT+3TC+LPV/rtoABC+3TCLPVrca
beconsideredtoreducethepillburdenandpreservethean
advantageofNRTË'ssequencing
Ifstable,childrencanbetransitionedtoTDE+3TC
+DTGwhen
theyreach30kg
20-30kgABC+3TC+DTG
30kg TDF+3TC+DTG
3TC:lamivudine;ABC:abacavir;AZT:zidovudine:DTG:dolutegravir;EFV:efavirenz;LPV/r:lopinavir/ritonavir;
NRTI:nucleosidereverse-transcriptaseinhibitor;NVP:nevirapine;TDF:tenofovirdisoproxilfumarate.
Source:(24)

86. 399
AIDS
womenof
childbearing
potential
should
have
to
g
pregnancy
testing
prior
to
initiation
or
PER
gnan
womanof
child-bearing
potential
Wno
's
PCbed
dolutegravir
shouldbe
counselled
tO
usedn
Ciective
birth
control
method
until
she
completes
tinePe
en.regnant
women
exposed
to
D10
should
de
monitored
for
neural
tube
defects,
especially
if
the
expOsure
Occurred
during
the
first
trimester.
A
All
fexposure
prophylaxis
(PEP)
o5
PEP
for
HlV
consistsofa
comprehensive
setof
services
ection
developingn
an
exposed
person,
nrevenetaid
care;
counselling
and
risk
assessmeni
2aing.
HIVEnt
the
short
1erm
(z6
days)
provision
of
and
counselling:and,
depending
onthe
risk
Use
of
co-trimoxazole
prophylaxisfor
HIV-related
infections
(22)
ettoviral
drugs,win
Support
ànd
jollow.-up.
antrero
bilityfor
posÍ-exposure
prophylaxis
Post-exposure
propnylaxis
5houldbe
offered.
and o-trimoxazole
is
a
fixed
dose
combinationof
fwo
microbial
drugs
(sulfamethoxazole
and
trimethoprim/
that
Coversa
varietyof
bacterial,
fungal
and
protozoan
intections.
he
therapyis
feasible,
well
tolerated
and
inexpensive
nervention
for
people
living
with
HlV
to
reduce
Hiv-related
morbidityand
mortality.
The
WHO
recommendations
(2016)
TOrthe
useof
co-frimoxazole
is
summarized
in
lable
8.
TABILE
as
earlyàs
possibe.
1oall
individuals
with
miiated
thas
the
potential
1or
HIV
transmission,
and
ideally
witinz
tiours
essment
for
eligibility
shouldbe
based
onthe
HIV
dalus
of
the
source
whenever
possible
and
may
includee
ronsiderationof
bacKground
prevalence
and
ocal
psure
nat
has
epidemologiCal
patfeTns,
3
Exposures
thatiay
wartant
posi-exposure
prophylaxis moxtiO(20
Lse
of
co-trimoxazoie
for
fHlV
related
mtections,
inciude.
parenteral
or
mucOus
membrane
cxposure
(sexual
exposureand
splashes
to
1ne
eye,
noseof
oral
cavily):
Aduts
(including
pregnant
women
Co-frimoxazole
prophylaxisis
recommendedfor
severeor
advaiced
HIVinical
disease
(WHO
stage3
or4)
and/or
fora
CD4
count
350
cells.m.
n&eltings
where
malaria
and/or
severe
bacterial
infections
are
highly
prevslent.
co-trimoxazole
prophylaxis
shouldbe
inifiated
regardlessof
CD4cel
countor
WHO
stage.
and
the
following
bodily
fuids
may
posea
riskof
HIV
infection:
blood.
blood-stained
saliva,
breastmilk,
genital
secietionsand
cerebro8pinal,
ainiolic,
sectal,
peritones,
syiovial,
pericardial
ot
pleural
lluids.
4
Exposure
thatdoes
not
equite
pOst-exposure
proptiylasjs
iticlude
a.uhen
the
exposed
individualis
alteadyHV
positive:
b.uhen
the
sourceis
established
tobeHV
negafive;
Co-frimoa2ole
prophylaxis
maybe
discontinued
in
adults
fincuding
pregnant
swomen)
with
HIV
infection
who
are
clinically
abie
on
antireftosviral
iheropy,
with
evidenceol
immune
ecovery
and
vitsl
suppestion,
n
seftings
where
malarin
and/or
sevete
bacterial
intections
are
highly
prevalent,
co-trimOx1zole
prophylaxis
sliould
be
contiived
tegatdess
ofCDa
cell
countor
WiiO
cinical
stnge.
.exposurefo
bodily
fluidshaf
do
nof
posea
signifant
risk:
1ears,
non-bloOd-stained
saliva,
Uine
and
su
infarils,
chidrenand
odoleseents
ASSeSHentoffhe1lV
stalus
ofthe
exposed
iridividual
StoNidrotbea
banier
1o
inilialin9,
post-expOsure
Pophyiai8.In
emergency
situalions
where
HIVtesting
and
DUITINing
isnof
readily
availablebutthe
potential
H1IVr1sk
Bg
Orifhe
exposed
personefuses
inilial
testing9.post
20Le
prophylaxis
shouidbe
iniliatedandHv
1esting
ard
CDunselling
underlakenassoonas
pos5iDC.
Co
trimoxAzole
uophylaxisis
recommendedfor
intants,
children,
and
adoescents
with}91,
frespectiveof
ciinicaland
tnmune
conditions,i'iotity
shouidb
ven
toáll
children
youngerthan
yearsold
iegstdlessofCDicell
count
orclinicalstogeond
to
children
with
severeor
advaneedHv
clinicaldisease
(WfHOclinical
$139e3
o4}and/orthose
wiithCI4S350
cells/mn
In
settingswithahigh
prevalence
ofmalarin
and/or
severe
bocterial
infections.
co-trimoxazole
propiylaxts
sthouldbe
continueduntil
aduithood
irespective
of
antiretroviral
therapy
rovision.
In
settingswithlow
prevalenceforboth
malariäand
bacteria!
inlections,
co-trimaxazole
prophylaxis
maybe
discontinuedfor
children5yearsolageandolderwho
areclinicallystablearid/or
virellysuppressedon
antiretrovira!therapyloratleast6months
andCD4>350
cells'mm.
PEPregimen(25)
e
ug
PLP
Tegimens
arenowthe
recommended
to
all
exposures
ouwing1othe
satetyna
Dy
ofnewHIVdrugs.The
guidelines
nolonger
Sssing
the
severityof
Cxposure.
There
are
some
ircumstances,
however,
in
which2-drug
?egmen
UCa,
especiallywhen
recommended
antiretroviral
H iOS
are
unavailableorthere
is
concerna00ut
adherence
problemsor1oxicity.Anexpertshoula
edif
2-drugregimen
isbeing
considerd
e
preferredHIV3-drugPEP
regimen
israltegravir
400mg
POtwicedailyplus
Truvada
(ienofovirDr
emtricitabine200mg)
1
POoncedaily.
2016
guidelinesfor
antiretroviral
pOstexposure
HIV.exposed
infants
Co-trimoxazole
prophylaxisisreconmended
forHIV.exposed
infantsfrom4-6weeksofageàndsiouldbecontinueduntilHIV
infectionhasbeen
exciudedbyàn
age-appropriateHiVtestto
establishfinal
diagno0S1saltercOnpieteccssattonofbreast-feeding.
LPViris
recommendedasthepreierredthirddrugforHivpost.
exposureprophylaxisamongchildrenyoungerthan10years.
Anage-appropriateaiternativeregimencanbeidentitiedamong
ATV,
RAL,DRV,EFVandNVP
dered.
ecom
non-Occupational
exposuretoHIV
doldeither
raltegravir
(RAL)400mgtwicedalyor
enofoDIG)
5Omgdailyin
combination
with
tegravir(DTG}5UmgaayITDE)300mga
Ovidisoproxilfumaral
emtricitabine
(FTC)20Undailyasthepreferred
regimenin
asoah
ànd
adolescents.
DolutegravirproVides
a
Deonce-dailyalternative
toraltegravir.
HIVand
TBcoinfection
Routine
co-trimoxazoleprophylaxisshouldbeadministeredtoall
HIV-infectedpeoplewithactivelBdiseaseregardlessofCD4cell
counts.
Source:
(22)

87. EMERGINGANDRE-EMERGINGINFECTIOUSDISEASES401
ansmitted
throughair,waterorfood.Theillnessis
Characterizedbysuddenonsetoffever,intenseweakness,
musclepain,headache,sorethroat,vomiting,diarrhoea,
dsn,
impairedkidneyandliverfunctionsandinsomecases
bothinternalandexternalbleeding.Currentlythereisno
5pecitictreatmentforthisdisease.However,byintensive
supportivecare,themortalitycanbereducedandspread
Othediseasecanbepreventedbyinstitutingspeciic
niectioncontrolmeasures.Thereisnovaccine
againstebola(3).
Thefactorsresponsioleioremergenceandre-emergence
ntiousdiseasesare:(1)unplannedandunder-
nedurbanizatio overcrowdingandrapid
plationarowth;(3)poorsanitation;(4)inadequate
hlichealthintrastructure;()resistancetoantibiotics;
Pncreasedexposureothumanstodiseasevectorsand
nature;(7)rapidandintense
reservoirsofinfection
international
ravet,dnd(o)microbialgeneticmutation
Emergingdiseases
Duringthepast30years,atleast30newdiseaseshave
emergedtothreatenthehealthofhundredsofmillionsof
Deople.Formanyofthesediseasesthereisnotreatment,
Cureorvaccineanathepossibilityofpreventingor
controllingthemislimited.
TheUnitedStateshasseentheemergenceofhantavirus
pulmonarysyndrome,characterizedbyrespiratorytailure
andacasefatalityrateofover50%.Since
itwasfirst
recognizedin1993,thistypeofhantavirusintectionhas
beendetectedinmorethan20statesinthatcountry,and
nasalsoSurtacedinArgentinaandBrazil.Thishantavirus
is
Emerginginfectiousdiseasesarethosewhoseincidence
inhumanshasincreasedduringthelasttwodecadesor
carriedbyrodents,
particularlydeermice.Other
whichthreatentoincreaseinthenearfuture.Thetermalso
referstonewly-appearingintectiousdiseases,ordiseases
thatarespreadingtonewgeographicalareassuchas
cholerainSouthAmericaandyellowfeverinKenya.
hantaviruseshavebeenrecognizedformanyyearsinAsla,
wheretheycausehaemorrhagicfeverwithrenal
involvementinhumans.
Epidemicsoffoodborneandwaterbornediseasesdueto
neworganismssuchascryptosporidiumornewstrainsof
bacteriasuchasEscherichiacolihavehitindustrialized
Thediseasesinquestioninvolveallthemajormodesof
transmission
-theyarespreadeither
frompersontOperson,
anddevelopingcountriesalike.TheOl51:Mstrain
or
byinsectsoranimals,orthroughcontaminatedwateror
food.Themostdramaticexampleofanewdiseaseis
COVID-19intheyear2019.TheongoingCOVID-19
pandemichaschangedthewholeworldwithvirtualglobal
lockdown,socialdistancinganduseofmaskastheonly
weaponagainsttheuncontrolledspreadofthedisease.First
caseofCOVID-19wasreportedinthemonthofNovember,
2019andon11thMarch,2020,itwasdeclaredapandemic
bytheWHO.Asof19thFeb.,2021about110,877,097
caseswith2,453,572deathswerereportedworldwide.
Although,nowvaccinesareavailableagainstCOVID-19,the
diseaseisyettocomeundercontrol.Newstrainsofthevirus
arealsonowincirculation(1).
E.coliwasfirstreportedin1982andhassincethenbeen
implicatedinmanyseriousoutbreaksofdiarrhoealillness,
sometimesleadingtokidneyfailure.Thestrainhasbeen
linkedtoundercookedhamburgerbeefandunpasteurized
milk.Acompletelynewstrainofcholera,0139,appearedin
south-easternIndiain1992andhassincespreadnorthand
westtootherareasofIndia,intowesternChina,Thailand
andotherpartsofouth-EastAsia.
Thethreatofanewglobalinfluenzapandemicis
increasing.Majorshiftsinthemake-upofinfluenzaviruses
occurevery20yearsorso,triggeringlargeepidemicsin
manypartsoftheworld,andcausingmanythousands
of
deaths.Thenextsuchshiftisexpectedtotakeplacevery
soon.Epidemicstrainsofinfluenzavirusesoriginatefrom
China.Iheinthuenzavirusiscarriedbyducks,chickensand
pigsraisedincloseproximitytooneanotheronfarms.The
exchangeofgeneticmaterialbetweentheseviruses
producesnewstrains,leadingtoepidemicsofhuman
infiuenza,eachepidemicbeingduetoadifferentstrain.
CurrentlyavianH5NIisthestrainwithpandemicpotential,
sinceitmightadaptintoastrain
thatiscontagiousamong
humans.Since1997,478caseswith286deathshavebeen
reportedtoWHO.ThefirstcasewasfromHongKong.Other
countriesinvolvedareCambodia,Indonesia,Thailandand
VietNam(6).Inlate2002,anewdiseasecalledSARSwas
AIDS,causedbythehumanimmunodeficiencyvirus
(HIV).Theexistenceoftheviruswasunknownuntil1983.
About38millionpeoplearelivingwithHVgloballyin
2019.1.2millioncaseswith690,000deathswerereported
worldwidein2019(2).
A
newbreedofdeadlyhaemorrhagicfevers,ofwhich
tbola
virusdisease(previouslyknownasEbola
haemorrhagicfever)isthemostnotorious,hasstruckin
Alrica.EbolaappearedforthefirsttimeinZaireandsudan
ni976.
Sincethenithasappearedperiodically.Ebolavirus
mber
ofFiloviridaefamilyandcomprisesof5distinct
pecies Zaireebolavirus;Restonebolavirus;udan
ebolavirus;Taiebolavirus;andBundibugyoebolavirus.
erecentepidemicstartedinDecember20 n
neaandspreadtoSouthAfrica.By.8thApril2015,
al
of25,515caseshavebeenreportedwithover
U00
deaths.Casefatalityratemaybeashigh
as
percent.Ebolahasincubationperiodof2-21days,and
Ainiectiveduringthisperiod.Asymptomatic
casesare
Ot
infective.Thevirusistransmittedthroughdirect
tn
theblood,organs,bodysecretionsorother
reportedfromChinawithrapidspreadtoHongKong,
Singapore,VietNam,laiwan,andToronto.During2003,
8,422SARScaseswerereportedfrom30countrieswith916
fatalities(7).Morerecently,pandemicduetoinfluenzaA
(H1N1)2009strainiscontinuingworldwideinvolving214
countries,alreadytaking18,156lives.Newstrainssuchas
thoseofcholeraandintluenzadonotfollowtheusual
patternofbeingmorecommoninyoungerpeople.They
affectalagegroups,sinceolder
peoplehavenotacquired
immunitytothemfrompreviousinfection.bo
idsofinfectedanimalslikechimpanzees,gords
eys,fruitbatsetc.Humantohumantransmissions
ere
0od
orbodyfluidsofaninfectedsymptomatic
ha orthrough
exposure
toobjects(suchasneedles)that
Encontaminatedwithinfectedsecretions.Itisnot
Table
1
summarizestheaetiologicalagentsandinfectious
diseasesinhumansand/oranimalsrecognizedsince1973.
Theyearmaydifterfromfirstappearanceandfirst
identificationofcases.
www.a OSA 3
AT
20Osassar

88. Males
Females
BothsexesNON-COMMUNICABLE
DISEASES
uterus)andfromthe
skin
epithelium;(b)
Sarcomas,
which
arise
from
mesodermal
cells
constitutingthe
various
connective
tissues
(e.g.fibroustissue,fatand
bone);and
(c)
Lymphomas,
myelomaand
leukaemias
arisingfromthe
cellsofbone
marrowand
immune
systems.
428 3.929,973,8363,864,824,7127,794,798.8d0
9,227,484 19,292.789Population
10,065,305
Numberofnew
186.0 201.0cancercases
222.0
Age-standardized
incidencerate
(World)
Riskofdeveloping
cancer
beforetheageofTheterm
"primary
tumourisusedtodenote
cancerin
theorganoforigin,while
"secondarytumourdenotes
cancerthathasspread
toregionallymphnodesand
distant
organs.Whencancercellsmultiplyandreachacriticalsize,
thecancerisclinicallyevidentasalumporulcer
localizedto
theorganoforigininearlystages.Asthediseaseadvances,
symptomsandsignsofinvasionanddistant
metastases
become
clinicallyevident(1).
22.6 18.6 20.4
75
years(%)
4,429,323 9,958,1335,528,8110
Numberof
cancerdeaths
120.8 84.2 100.7
Age-standardized
mortalityrate
(World)
Riskofdyingfromcancer
eforethe
ageof75
years(%)
5-year
prevalentcases
24,828,480
Top5mostfrequent
cancersexcluding
12.6
8.9 10.7
25,721,8007 50,550,287
Problemstatement
Breast
Lung
Colorectum
Prostate
BreastLung
ProstateColorectum
Lung
Cervixuteri
Thyroid
WORLD
Intheyear2020,theglobalburdenofcancerrosetoan
estimated19.292millionnewcaseswith9.958million
deaths.Themostcommoncancerdiagnosed
werecancer
breastfollowedbycancerlung,prostate,colonandstomach.
Themostcommoncauseofdeathduetocancerwascancer
Colorectum
Stomach
Liver
non-melanoma
skincancer
Stomach
rankedbycases)
lung,cancerliver,cancerstomachandcancerbreast.The
summarystatisticsfortheyear2020isasfollows(2)
Theagestandardizedincidencerateoftop10
cancersby
sex,andagestandardizedincidenceandmortalityrateof
top10cancersworldwideareasshowninFig.
1and
12.
Males OFemales
47.8
Breast
14.6
31.5
Lung
16.2
23.4
Colorectum
30.7
Prostate
7.0
15.
Stomach
14.1 5.2
Liver
13.3
Cervixuteri
10.1
Thyroid
Oesophagus 9.3
3.6
Bladder
9.5 2.4
50 60
50 50 40 30 20 10 0 10 20 30 40
ASR(World)per100,000
FIG.1
Agestandardized(World)incidenceratesbysex,top10cancers
Source:(2)
Incidence Mortality
Breast
Prostate
47.8
13.6
30.7
7.7
Lung 22.4
18.0
Colorectum
19.5
9.0
Cervixuteri
Stomach
13.3
7.3
11.1
7.7
Liver
9.5
8.7
Corpusuteri
8.7
1.8
Ovary
6.6
4.2
Thyroid
6.6
0.43
60 50 40 30 20 10 0 10 20 30 506040
ASR(World)per100,000
FIG.2
Agestandardized(World)incidenceandmortalityrates,top10cancers
Source(2)

89. CANCER 429
nce
ofgrowingandageingpopulations,asINDIAquence
s
As
aCosintheprevalenceanddistributionofmain
changes
factorsmicdevelopment,developingcountriesare
wio-econnatelyaffectedbytheincreasingnumbersof
cer,severalofwhichareassociatedwithndia,
theNationalCancerRegistryProgrammeofthe
ICMRprovidesdataonincidence,mortaltaand5hospital
OTcancerfrom28population-basedregistriesand5hospltai
basedregistries.
sproport
ance
sexes
combined,one-haltofallcasesand
roent
ofcancerdeathsareestumatedtooccurinAsia
8.3
Dehere59.5percentof
theglobalpopulation
ZU TOpeaccountsforZZ.8percentofthetotal
es
ases
and19.6
percentofthecancerdeaths,
Tepresents9.7percentoftheglobalpopulation,
thougtheAmericas'20.9percentofincidenceand
nindia,intheyear2020,thenumber
ofprevalent
Cases
ears)
isabout2,720,251,thenumberof
newca
,oZ4,413andthenumberofdeaths851,6/8,ne
umarystatisticalsituationfortheyear2020
inthe
countryis
asfollows
2per
centofmortalityworidwide.Incontrasttoother
because
thedifferentdistributionof
cancertypesand
Summarystatistics2020,India
ollowed
theshareofcancerdeathsinAsia(58.3percent)
TeAfrica
na
(7.2percent)arenigher
thantheshareof
Males
FemalesS
Bothsexes
717,100,976
662,903,415
1,380,004,378
678,383
Population
Numberofnew
646,030
1,324,413
cancercases
(49.3percentand5.7percent,respectively)
97.1
cidence
95.7 99.3
Age-standardized
incidencerate
highercasetatalityratesintheseregions(3).
The"Westernizationtrends:
Aslowhuman-development
index(HDI)countriesbecome
moredevelopedthrough
rapidsocietalandeconomicchanges,theyarelikelyto
become"westernizedASSuch,thepatternofcancer
incidence
islikelytotollowthatseeninhighHDIsettings,
withlikelydeclineincancerincidencerateofcervixuteri
andstomach,andincreasingincidenceratesofbreast,
prostateandcolorectalcancers.Thiswesternizationeffectis
aresultofreductioninintection-relatedcancersand
increase
incancersassociatedwithreproductive,dietary
andhormonalriskfactors(4).
10.5
10.4
Riskofdevelopingcancer
beforetheageot
75years(70
10.4
438,2
413,381
851,678
Numberof
cancerdeaths
65.4
61.0
63.1
Age-standardized
mortalityrate
6.7
7.1
Riskofdyingfromcancer
betorethe
ageot7years
(o)
-yearprevalent
cases1,208,835
Top5mostfrequentLip,oralcavity
cancersexcluding
non-melanoma
skincancer
(rankedbycases)
Oesophagus
7.4
o)
1,511,4162,720,251
Breast
Lung
Stomach
Breast
CervixuteriLip,oralcavity
Ovary Cervixuteri
Lung
ColorectumLip,oralcavity
Colorectum
For
anydisease,therelationshipofincidencetomortality
sanindicationotprognosis.Similarincidenceandmortality
ratesbeingindicativeofanessentiallyfatalcondition.Thus,
ungcanceraccountsformostdeathsfromcancerin
thhe
World(1.7million)annually,since
itismostinvariably
associatedwithpoorprognosis.Ontheotherhand,
Colorectum
Source:(7)
Theagestandardizedincidencerateoftop10cancersby
sex,andagestandardizedmortalityrateandincidencerate
perlakhpopulation
inIndia
isasshowninFig.3and4(7).
appropriateintervention
isofteneffectiveinavoidingfatal
Thefivemostfrequentcancersinmenwerecancerlip
andoralcavity,lung,stomach,colorectumandoesophagus,
andinwomen,cancerbreast,cerviXuteri,ovary,lip,oral
cavityandcolorectum.Cancerinmalesweremostlytobacco
related.nwomen,cervicalcanceriscloselyassociatedwith
poorgenitalhygiene,earlyconsummationofmarriage,
multiplepregnancies,andcontactwithmultiplesexual
partners.It
isalsoreportedthatbreastcanceris
proportionatelyontheincreasein
atewmetropolitanareas
ofIndia.Thisappearstoberelatedtolatemarriage,birthof
thefirstchildatalate
age,tewerchildren,andshorter
periodsofbreast-feeding,whichareincreasinglycommon
practiceamongtheeducatedurbanwomen(8).
Facilitiesforscreeningand
propermanagementofcancer
patientsaregrosslylimitedinIndia.Morethantwo-thirdsof
cancerpatientsarealreadyinanadvancedandincurable
stageatthetimeof
diagnoSIs.APpropriatestrategiesare
beingdeveloped,includingCreatingpublicawarenessabout
cancer,tobaccocontrolandapplicationof
selforassisted
screeningtechniquefororal,cervical,andbreast
cancers
Outcomefollowingdiagnosisofbreast
cancer.Hencethis
particularcancer,whichranksecondintermsofincidence,
not
amongthetopthreecausesofdeathfromcancer
are
Tespectivelycancersofthelung,stomach,and
ver.
most
conspicuousfeatureofthedistributiono
ersDetweenthesexesisthemalepredominance
orlung
leOState,colorectal,stomachandlivercancerare
uCn
morecommoninmales.Cancer
ororeast,
fomo lung,cervix,uteriandstomacharecommonIn
rorthemostpart,
differencesindistribution
n
thesexesareattributabletodifferencesinexposure
roveagentsratherthantovariation
intne
he
forothertumourtypes,including
cancersO
Striana
colorectum,thereislittledifferenceinthe
sex
incid Generallyspeaking,therelationsnip
mortalityisnotaffectedbysex.Thusfor
Pancreateprognosis
followingdiagnosisofliveror
lemalecCancerisdismalforbothmales
and
herapu Othertumourtypesaremoreresponsive
tO
at
cancersofbreast,
prostateanduterine
gnosediause
ofdeathinonlyaminorityofpatients
ànct
Timetrends
ervixare
thecauseO
Fewdecadesago,cancerwasthesixthleadingcauseof
deathinindustrializedcountries,today,
itisthesecond
leadingcauseotdeath.Ihereareanumberot
reasonsforthis
increase,
thethreemainonesbeing
alongerliteexpectancy,
moreaccuratediagnosisandtheriseincigarettesmoking,
(6)
heburden
ofcance
tunpedanddancer
is
distributed
unequally
between
develor
nddevelopingcountries,
withparticular
cancer
ypes
itingaifferentpatternsofdistribution.

90. 430 NON-COMMUNICABLE DISEASES
Males Females
Breast
iiias 26,8
Lip,oralcavity
Cervixuteri
4.6
n I8.0
Lung
7,8 .1
Colorectum
Oesophagus
6.1 3.4
Stomach
6.1 2.9
Leukaemia
4.2
Ovary
Prostate
40 30 20 10 0 0 30
ASRper100,000
FIG.3
Agestandardizedincidenceratesbysex,top10cancersinIndia(2020)
Incidence Mortality
Breast z3,8
13.3
Cervixuteri 18.0Le
Lip,oralcavity
Ovary
b.7
Prostate
5.5
2.7
Lung
| 4.92L 202d39
.4
Colorectum
4.8EM 2.8
Oesophagus
**
Stomach 4.5
Leukaemia
3.6 2.6
40 30 20 10 10 20 30 840
ASRper100,000
FIG.4
Agestandardizedincidenceandmortalityrates,top10cancersinIndia(2020)t 0
especiallyamongmales.Theoverallratesdonotreflectthe
differenttrendsaccordingtothetypeofcancer.Forexample,
therehasbeenalargeincreaseinlungcancerincidenceand
thestomachcancerhasshownadecliningtrendinmost
developedcountriesforreasonsnotunderstood.
importanttonotethatthesetwokindsofcancerareeasily
accessibletorphysicalexaminationandamenableto
eary
diagnosisbyknowledgealreadyavailable.i.e.,goodclinica
examinationandexfoliativecytology.The
cureratetorthese
neoplasmaisalsoveryhighiftheyaretreatedsurgicallya
stagesIandil.Butuntortunately,inmostcases,thepatient
presentthemselvestoamedicalfacilitywhenthedisease
faradvancedandisnotamenabletotreatment.Thisisth
cruxoftheproblemn.
Cancerpatterns
Therearewidevariationsinthedistributionofcancer
throughouttheworld.Thatcancerofthestomachisvery
commoninJapan,andhasalowincidenceinUnitedStates.
Thecervical_cancerishighincolumbiaandhasalow
incidenceinJapan.IntheSouth-EastAsiaRegionofWHO,
thegreatmajorityarecancersoftheoralcavityanduterine
cervix.Theseandotherinternationalvariationsinthe
patternofcancerareattributedtomultiplefactorssuchas1.ENVIRONMENTAL FACTORS
environmentalfactors,foodhabits,lifestyle,geneticfactors
oreveninadequacyindetectionandreportingofcases.
Causesofcancer
Aswithotherchronicdiseases,cancerhasamultitactor
aetiology.
Hospitaldataclearlyindicatesthatthetwoorgansites
mostcommonlyinvolvedare:()theuterinecervixin
women,and(i)theoropharynxinbothsexes.Thesetwo
sitesrepresentapproximately50percentofallcancercases.
Boththesecancersarepredominantlyenvironmentrelated
andhaveastrongsocio-culturalrelationship.
Itisalso
Environmentalfactorsaregenerallyheldresponsio
80to90percentofallhumancancers.ne
environmentalfactorsidentifiedsofar
incu
(a)TOBACCO:Tobaccoinvariousformsofits
usage
smoking,chewing)isthemajorenvironmentalcaa
cancersofthelung,larynx,mouth,pharynxoesopato
oladder,pancreasandprobablykidney:Ithasbeenes
is
no
that,intheworldasawhole,cigarettesmoki

91. 434 NONCOMMUNICABLE DISEASES
acknowledgedasresponsibleforamuch
dinmore
wider
than
95%
inical
an
motivationforchanginglifestylessupportedbylegislative
measureslikebanningorrestrictingthesaleoftobacco.
subclinicallesions.Thevirusisfound
thecancers.Currentevidence
necessarybutnotsufticientcauseofthediusi
researchersarenowtryingtodefineotherco-factore
suggests
thatthe
b.SECONDARYPREVENTION thedisease
an
Oralcancersareeasilyaccessibleforinspectionallowing
earlydetection.Ifdetectedearly,possiblyatthe
precancerousstage,theycanbetreatedorcured.The
precancerouslesionscanbedetectedforupto15years,
priortotheirchangetoaninvasivecarcinoma.Leukoplakia
canbecuredbycessationoftobaccouse.Themain
treatmentmodalitiesthatofferhopearesurgeryand
radiotherapy(30).Indevelopingcountriesover50percent
oforalcancersaredetectedonlyaftertheyhavereachedan
advancedstage(15).
RISKFACTORS
(a)AGE:Cancercervixaftectsrelatively
youna.
withincidenceincreasingrapidlyfromtheageof2men
thenlevellingoff,andtinallyfallingagain.(b)cE5
WARTS Pastand/orpresentoccurrenceofclinical
L
wartshasbeenfoundtobeanimportantriskfactnta
(c)MARITALSTATUS:Casesarelesslikelytobes
morelikelytobewidowed,divorcedorsenarngle
havingmultiplesexualpartners.Thefactthat
cancor
ofthe
Theprimaryhealthcareworkers(villagehealthguides,
andmulti-purposeworkers)areinastrategicpositionto
detectoralcancersatanearlystageduringhomevisits.
Theycanprovetobeavitallinkandakeyinstrumentinthe
controloforalcancerindevelopingcountries(31)
andpracti
unknownamongvirginssuggeststhatthediseasecll
linkedwithsexualintercourse.(d)EARLYMARRIAGEF
marriage,earlycoitus,earlychildbearingand
ron
cervixisverycommoninprostitutes
eated
childbirthhavebeenassociatedwithincreasingid
(e)ORALCONTRACEPTIVE PILLSThereis
ro
enewed
thedevelopmentofinvasivecervicalcancer(34).A
recent
2.Cancerofthecervix
concernaboutthepossiblerelationshipbetweenpill
usea
eand
Cervicalcanceristhefourthmostfrequentcancerin
womenwithanestimated6,04,000newcasesin
2020
representing6.6percentofallfemalecancers(3).During
theyearabout3,42,000womendiedofcervicalcancer,
whichcomesto3.1percentofalldeaths
women(3).Approximately90percentofdeathsfrom
cervicalcanceroccurredinlowandmiddleincome
countries.Widevariationsinincidenceandmortalityfrom
thediseaseexistbetweencountries.Casesanddeathshave
declinedmarkedlyinthelast40yearsinmostindustrialized
countries,partlyowingtoareductioninriskfactors,
butmainlyasaresultofextensivescreeningprogrammes.
Morelimitedimprovementshavebeenobservedin
developingcountries,wherepersistentlyhighratestendto
betherule(1).
WHOstudyfindsanincreasedriskwithincreaseddurati
ration
ofpilluseandwiththeuseoforalcontraceptiveshigh
oestrogen(35).(f)SOClO-ECONOMIC CLASS:
Cancer
cervixismorecommoninthelowersocio-economicgrounsduetocancerin
reflectingprobablypoorgenitalhygiene.
PREVENTIONANDCONTROL
(a)PRIMARYPREVENTION:Untilthecausative
factors
aremoreclearlyunderstood,thereisnoprospectofprimar
preventionofthedisease(32).Itmaybethatwithimproved
personalhygieneandbirthcontrol,cancerofthecervixuteri
willshowthesamedeclineindevelopingcountriesasalready
experiencedinmostofEuropeandNorthAmerica(36).
(b)SECONDARY PREVENTION:Thisrests
onearly
detectionofcasesthroughscreeningandtreatmentby
radicalsurgeryandradiotherapy.The5-yearsurvivalrateis
virtually100percentforcarcinomainsitu,79percentfor
localinvasivediseaseand45percentforregionalinvasive
disease(20).Cancercervixisdifficulttocure
once
symptomsdevelopandisfatalifleftuntreated.Prognosisis
stronglydependentuponthestageofdiseaseatdetection
andtreatment
InIndia,cancercervixconstitutes9.4percentofall
cancerincidenceamongwomen.Theagestandardized
incidencerateisabout18.0per100,000population.The
estimateddeathswere77,348in2020(7)
NATURALHISTORY
(a)Thedisease:Cancercervixseemstofollowa
progresivecoursefromepithelialdysplasiatocarcinomain
situtoinvasivecarcinoma(Fig.5).Thereisgoodevidence
thatcarcinomainsitupersistsforalongtime,morethan
8yearsonanaverage(20).Theproportionofcases
progressingtoinvasivecarcinomafrompreinvasivestageis
notknownitmayaverage15to20yearsorlonger(32).
Thedurationofthepreinvasivestageisalsonotknown.
Thereisevidencethatsomeinsitucaseswillspontaneously
regresswithouttreatment.Oncetheinvasivestageis
reached,thediseasespreadsbydirectextensionintothe
lymphnodesandpelvicorgans.
3.Breastcancer
Femalebreastcancerhasnowsurpassedlung
canceras
theleadingcauseofglobalcancerincidencein2020
withanestimated2.3millionnewcases,representing
11.7percentofallcancercases.ItisthefifthleadingcauS
ofcancermortalityworldwide,with6,85,000deatns
Amongwomen,breastcanceraccountsfor1in4
cance
casesandfor
1
in6cancerdeaths,rankingfirstforinciden=
inthevastmajorityofcountries(159of185countries),
alne
formortalityin110countries.Thereareexceptions,
mo
notablyintermsofdeaths,withthediseaseprecedea
lungcancerinAustralia/NewZealand,NorthernEurop
NorthernAmerica,andChina(partofEasternAsia)an
cervicalcancerinmanycountriesinsub-SaharanAfrica
Incidenceratesare88percenthigherintranst
Countriesthanintransitioningcountries(55.9and29.
T00,000,respectively),withthehighestincidence
80
per100,000)inAustralia/New
Zealand,We
Europe(Belgiumhastheworld'shighestinclae
NormalDysplasia
CancerInvasive
insitu cancerepithelium
FIG.5
Hypotheticalmodelofthenaturalhistoryofcancercervix
(b)Causativeagent:Thereisevidencepointingto
Humanpapillomavirus(HPV)sexuallytransmittedas
hecauseofcervicalcancer(33).Thisviruswasonce
upposedtoproduceonlyvegetantwarts,butnow

92. specificeffectsofdiabetes
include
retinopathy,nenh.
and
neuropathy,
amongother
complications.
Peonpathy
diabetesarealsoatincreasedriskofotherdiseasesinoth
heart,
peripheralarterialand
Cerebrovasculardicng
obesity,
cataracts,erectile
dystunction,andnon-alse,
fattyliverdisease.Theyarealsoatincreasedrisk
lic
infectiousdiseases,suchastuberculosis(1).
438
NON-COMMUNICABLE
DISEASES
44
Pike,M.C.etal(1983).Lancet,2:
926-929.
45.Frisch,R.E.etal(1981).
JAMA,246:
1559-1563
46.Muir,C.S.(1981).WorldHealth,Sept-Oct,pp8-11.
47.WHO(1985).WHOChronicle,39(3)109-111
48.WHO(1982).BullWHO,60(6)809-819.
49.Notani,PN.etal(1977)
Int.J.Cancer,14:115.
50.Jussawalla,D.J.andJain,D.K.(1979).
Brit.J.Cancer40:437.
51.WHO(1979).Techn.Rep.Ser.,
No.636.
52.Doll,R.andPeto,R.(1976).Brit.Med.J.,2:1525
creasedriskofsome
Classificationofdiabetes
(2019)
Ideallyasingle
classificationsystemfordiabetes
would
facilitatethreeprimary
purposes:clinicalcare,
ao
pathologyand
epidemiology.
Withthisinmind,
theE
group
considereditbestfodefineaclassiticationsystem
tha
prioritizes
clinicalcareandhelpshealth
professiona
chooseappropriatefreatment,andwhetherornotto
star
treatmentwithinsulin,particularlyatthetimeofdiagnosis
TheWHOclassificationofdiabetes
isasshowninTable1(2
DIABETES
MELLITUS xpe
Thetermdiabetesdescribesagroupofmetabolic
disorders
characterizedandidentifiedbythe
presenceof
hyperglycaemiaintheabsenceof
treatment.
heterogeneous
aetio-pathologyincludesdefectsininsulin
secretion,insulinaction,orboth,and
disturbancesof
carbohydrate,fatandprotein
metabolism.Thelong-term
The
TABLE
1
Typesofdiabetes
Changefromprevious
classification
Typeofdiabetes
Briefdescription
B-celldestruction(mostly
immune-mediated)andabsoluteinsulindeficiency;
onsetmostcommoninchildhoodandearlyadulthood
Type
1sub-classes
Type
1diabetes
removed
Type2sub-classes
Mostcommontype,variousdegreesofB-celldysfunctionandinsulinresistance;
commonlyassociatedwithoverweightandobesityType2diabetes
removed
Newtypeofdiabetes
Hybridformsofdiabetes
Slowlyevolving,
Similartoslowlyevolvingtype
1
inadultsbutmoreoftenhasfeaturesofthe
metabolicsyndrome,asingleGADautoantibodyandretainsgreater
B-cellfunction
Nomenclaturechanged
previouslyreferredtoas
latentautoimmuneimmune-mediated
diabetesofadults diabetesofadults(LADA)
Nochange
Ketosis-prone
type2diabetes
Presentswithketosisandinsulindeficiencybutlaterdoesnotrequireinsulin;
commonepisodesofketosis,notimmune-mediated
Otherspecifictypes
Monogenicdiabetes
Monogenicdefectsof
B-cellfunction
Monogenicdefectsin
insulinaction
Causedbyspecificgenemutations,hasseveralclinicalmanifestations
requiringdifferenttreatment,someoccurringintheneonatalperiod,others
byearlyadulthood
Causedbyspecificgenemutations;hasfeaturesofsevereinsulinresistancewithoutdefects
obesity;diabetesdevelopswhenB-cellsdonotcompensateforinsulinresistance
Variousconditionsthataffectthepancreascanresultinhyperglycaemia
(trauma,tumor,inflammation,etc.)
OccursindiseaseswithexcesssecretionofhormonesthatareinsulinantagonistsNochange
Updatednomenclature
forspecificgenetic
Diseasesoftheexocrine
Nochange
pancreas
Endocrinedisorders
Drug-orchemical-
induced
Somemedicinesandchemicalsimpairinsulinsecretionoraction,somecan
destroyB-cells
Nochange
Infection-relateddiabetesSomeviruseshavebeenassociatedwithdirectB-celldestruction Nochange
UncommonspecificformsofAssociatedwithrareimmune-mediateddiseases
immune-mediateddiabetes
Nochange
Othergeneticsyndromes
Sometimesassociated
Manygeneticdisordersandchromosomalabnormalitiesincreasetheriskof
diabetes
Nochangge
withdiabete
Unclassifieddiabetes Usedtodescribediabetesthatdoesnotclearlyfitintoothercategories.This
categoryshouldbeusedtemporarilywhenthereisnotacleardiagnostic
categoryespeciallyclosetothetimeofdiagnosis
Newtypesof
diabetes
Hyperglycaemiafirstdetectedduringpregnancy
Diabetesmellitusin Type1
ortype2diabetesfirstdiagnosedduringpregnancy
pregnancy Nochange
Gestationaldiabetes Hyperglycaemiabelowdiagnosticthresholdsfordiabetesinpregnancymellitus
diagnosticcriteria
Diagnosticcriteriaforgestationaldiabetesfastingplasmaglucose5.1-6.9mmol/Lor1-hourpost-loadplasmaglucose210.0m
Diagnosticcriteriafordiabetes:fastingplasmaglucose27.0mmol/Lor2-hourpost-loadplasmaglucose211.1mmolLor
Definedby2013
Hbalc248mmol/mol
or2-hourpost-loadplasmaglucose8.5-11.0mmol/L
L
Source
:
(2)

93. 439DIABETES
MELLSTCUS
(Insulin-dependentdiabet
aprevalenceofdiabetesin2014wasestimated
tobe
.7
inadultsaged
18++years(4).Theprevalence
ot
dlabeteswashighestintheEasternMediterraneankegion
nd
theKegionoftheAmericas(11%forbothsexes)
and
OwestintheWHOEuropeanandWesternPaciticKegions
7o
torbothsexes).Themagnitudeofdiabetesandotner
anormalities
ofglucosetoleranceareconsiderabiynigner
nantheaboveestimates
ifthecategories
oimpaet
astingand'impairedglucosetolerancearealsoincuded
1diabetes
mostsevereformofthedisease.Itsonsetistypically
uis)is
mdisusuallyseenin
nanaualslessthan30yearsof
unlethalunlesspromptiydiagnosecandtreated.This
f
diabetesisimmune-mediatedinover90percecentot
mdidiopathicinlessthanI0percentcases.Therate
stuctionofpancreaticcellisquitevariable,Rapidin
edividualsandslowinothers.1ype1
diabetesis
allyas
assOciatedwithketlosis
in
nSuntreatedstale.Itoccurs
stly
inchildren.negnest
among10-14TheestimatedprevalenceofdiabetesWas
latively
S
arup.butoccasionallyoccurinadults.Itisconsistentacrosstheincomegroup
alence(8%for
abolicdisorderinwhichcirculatinginsulinisvirtuallyincomecountriesshowedtheOe
ent.
plasmaglucagon,iseievated,andthepancreatic
|lsfailtorespondto
alnsunogenicstimuli.Exogenous
alin
isthereforerequiredtoreversethecatabolicstate,
vent
ketosis.,reduce
thehyperglucagonaemia,andreduce
valence
aisc
bothsexes),andtheupper-middle-incomecountries
snowed
thehighest(10%forbothsexes)(5).
Unfavourablemodificationoflifestyleanddietaryhabits
thatareassociatedwithurbanizationarebelievedtobethe
mostimportantfactorsforthedevelopmentofdiabetes.Ihe
prevalenceofdiabetesisapproximatelytwiceinurbanareas
thaninruralpopulation.
odglucose(8).
ype2diabetesismuchmorecommon
thantype
1
etes.Itisoftendiscoveredbychance.Itistypically
dual
inonsetandoccursmainlyinthemiddle-agedand
rly,frequentlymild,slowtoketosisandiscompatible
longsurvivalifgivenadequatetreatment.Itsclinical
ureisusuallycomplicatedbythepresenceofother
Abulkofevidencefromstudiesonmigrantsindicatesthat
neethnic,presumablygenetic,vulnerabilityotAsians
manifestsintodiabeteswhensubjectedtounfavourablelite-
styles.Population-based
surveyscompletedrecentlyin
Bangladesh,IndiaandIndonesiahaveshownconsiderable
increaseintheprevalencerateofthediseaseinbothurban
aseprocesses.
Gestationaldiabetesishyperglycaemiawithblood
osevaluesabovenormalbutbelowthosediagnosticof
petes.occuringduringpregnancy.Womenwith
ationaldiabetesareatanincreasedriskofcomplications
ngpregnancyandatdelivery.Theyandtheirchildren
alsoatincreasedriskoftype2diabetesinthefuture.
mpairedglucosetolerance(1GT)describesastate
rmediate-"at-risk"groupbetweendiabetesmellitus
normality.Itcanonlybedefinedbytheoralglucose
rancetest(seeTable3).
andruraldwellerswhencomparedtoresultsobtainedearlier.
Diabeticpatients,
ifundiagnosedorinadequatelytreated.
developmultiplechroniccomplicationseadingto
irreversibledisabilityanddeath.Coronaryheartdiseaseand
strokearemorecommonindiabeticsthaninthegeneral
population.Microvascularcomplicationslikediabeticrenal
diseaseanddiabeticretinopathyandneuropathyareserious
healthproblemsresultingindeteriorationofthequalityof
lifeandprematuredeath.Infact,diabetesislistedamong
thefivemostimportantdeterminantsofthecardiovascular
diseaseepidemicinAsia.Lowerlimbamputationareatleast
10timesmorecommonindiabeticthaninnon-diabetic
individualsindevelopedcountries,morethanhaliofall
non-traumaticlowerlimbamputationsaredueto
diabetes(5).Metabolicdisordersinpregnantdiabetic
womenaswellasthosecausedbygestationaldiabetes
(diabetesdiagnosedforthefirsttimeduringpregnancy)
poseahighhealthrisk,toboththemotherandfoetus.
ulinresistancesyndrome(SyndroineX)
obesepatientswithtype2diabetes,theassociationof
erglycaemia,hyperinsulinaemia,dyslipidaemiaand
eriension,whichleadstocoronaryarterydiseaseand
se,mayresultfromageneticdefectproducinginsulin
tance,withthelatterbeingexaggeratedbyobesity.t
beenproposedthatinsulinresistancepredisposesto
rglycaemia,whichresultsinhyperinsulinaemia(which
ormaynotbeofsufficientmagnitudetocorrectthe
rglycaemia)andthisexcessiveinsulinlevelthen
Tibutestohighlevelsoftriglyceridesandincreased
um
retentionbyrenaltubules,thusinducing
rlension.Highlevelsofinsulincanstimulate
inelialproliferationtoinitiateatherosclerosis(3).
Unfortunately,thereisstillinadequateawarenessabout
therealdimensionoftheproblemamongthegeneralpublic.
Thereisalsoalackofawarenessabouttheexisting
interventionsforpreventingdiabetesandthemanagementof
complications.Inadequaciesinprimaryhealthcaresystems,
whicharenotdesignedtocopewiththeadditionalchallenges
posedbythechronicnon-communicablediseases,resultin
poordetectionofcases,suboptimaltreatmentand
insufficientfollow-upleadingtounnecessarydisabilitiesand
severecomplications,oftenresultinginearlydeath.
Theage-adjustedmortalityratesamongthepeoplewith
diabetesare1.5to2.5timeshigherthaninthegeneral
population(6).InCaucassianpopulation,muchofthe
excessmortalityisattributabletocardiovasculardisease,
especiallycoronaryneartdiseaseamongstAsianand
AmericanIndianpopulation,renaldiseaseisamajor
contributor(6);whereasnsomedevelopingsocieties,
infectionsareanimportantcauseotdeath.Itisconceivable-
thatthedeclinein
mortalityduetocoronaryheartdisease-
whichhasoccurredinmanyattluentcountriesmaybehalte
orevenreversedifratesottype2diabetescontinuetorise
Thismayoccuritthecoronaryrisktactorsassociatedwith
blemstatement
RLD
abetesisan"iceberg"disease.Althoughincreasein
ineprevalenceandincidenceoftype2diabeteshave
redgloablly,theyhavebeenespeciallydramaticin
2lies
neconomictransition,innewlyindustrializea
esàndindevelopingcountries.Duringyear2014,
thne
dOCasesofdiabetesworlwide
isestimatedtobe
22
million,ofthesemorethan90percentaretypez
n
2016,anestimated1.6millionpeoplediedfrom
etess
Ohighbloodsugar(4).Morethan80percent
aeaths
occurinlowandmiddleincomecountries.
iagnoaent
i
prevalenceofhyperglycaemiadependson
ticcriteriausedinepidemiologicalsurveysThe

94. 442
NON-COMMUNICABLE DISEASES
b.HIGH-RISK
STRATEGY
purposes,the2-hourvalueafter75goralglucosemaybe
usedeitheraloneorwiththefastingvalue(11).Automated
biochemistryhasnowmadeitpossibletoscreenthousandsof
samplesforglucoseestimation.Thecriteriaforthediagnosis
ofdiabetes,proposedbyWHO,aregiveninTable3.
Thereisnospecialhigh-riskstrategyfortype1diat.
Atpresent,thereisnopracticaljustificationfores,
netic
counsellingasamethodofprevention(11).
Since
NIDDMappearstobelinkedwithsedentaru
style,over-nutritionandobesity,correctionofthese
reducetheriskofdiabetesanditscomplications.Sincoal.ay
canindirectlyincreasetheriskofdiabetes,itshotld
avoided.Subjectsatriskshouldavoiddiabetogenicdrugslit
oralcontraceptives.
Itiswisetoreducetactorsthat
promote
atherosclerosis,e.g.,smoking,highblood
pressure,elevatod
cholesterolandhightriglyceridelevels.These
programma
may
mosteffectivelybedirectedattargetpopulation
groups
life
Targetpopulation
Screeningofthewholepopulationfordiabetesisnot
consideredarewardingexercise(18,19).However,
screeningof"high-risk"
appropriate.Thesegroupsare:(i)thoseintheagegroup40
andover;(ii)thosewithafamilyhistoryofdiabetes;(ii)the
obese;(iv)womenwhohavehadababyweighingmore
than4.5kg(or3.5kginconstitutionallysmallpopulations);
()womenwhoshowexcessweightgainduringpregnancy,
and(vi)patientswithprematureatherosclerosis.
groupsisconsideredmore
2.Secondaryprevention
Whendiabetesisdetected,itmustbeadequatelytreated.
Theaimsoftreatmentare(ato
maintainbloodglucose
levelsasclosewithinthenormallimitsasispracticable(see
Table3),and(b)tomaintainidealbodyweight.Treatmentis
basedon(a)dietalone smallbalancedmeals
more
frequently,(b)dietandoralantidiabeticdrugs,or(c)diet
andinsulin.Goodcontrolofbloodglucoseprotectsagainst
thedevelopmentofcomplications,Pleaseseeinchapter10
"Nutritionandhealth"undertitle"Nutritionalfactorsin
selecteddiseasesfordetails.
Propermanagementofthediabeticismostimportantto
preventcomplications.Routinecheckingofbloodsugar,of
urineforproteinsandketones,ofbloodpressure,visualacuity
andweightshouldbedoneperiodically.Thefeetshouldbe
examinedforanydefectivebloodcirculation(Doppler
ultrasoundprobesareadvised),lossofsensationandthe
healthoftheskin.Primaryhealthcareisofgreatimportance
todiabeticpatientssincemostcareisobtainedatthislevel.
Glycosylatedhaemoglobin:Thereshouldbeanestimation
ofglycated(glycosylated)haemoglobinathalf-yearly
intervals.Thistestprovidesalong-termindexofglucose
control.Thistestisbasedonthefollowingrationale:glucose
inthebloodiscomplexedtoacertainfractionofhaemoglobin
toanextentproportionaltothebloodglucoseconcentration.
Thepercentageofsuchglycosylatedhaemoglobinreflectsthe
meanbloodglucoselevelsduringtheredcelllife-time(1e.
abouttheprevious2-3months)(20).
PREVENTIONANDCARE
1.Primaryprevention
Twostrategiesforprimarypreventionhavebeen
suggested:(a)populationstrategy,and(b)high-risk
strategy(11).
a.POPULATIONSTRATEGY
Thescopeforprimarypreventionoftype
1diabetesis
limitedonthebasisofcurrentknowledgeandisprobably
notappropriate(11).However,thedevelopmentof
preventionprogrammesfortype2diabetesbasedon
eliminationofenvironmentalriskfactorsispossible.Thereis
pressingneedforprimordialpreventionthat is,
preventionoftheemergenceofriskfactorsincountriesin
whichtheyhavenotyetappeared.Thepreventivemeasures
comprisemaintenanceofnormalbodyweightthrough
adoptionofhealthynutritionalhabitsandphysicalexercise
Thenutritionalhabitsincludeanadequateproteinintake,a
highintakeofdietaryfibreandavoidanceofsweetfoods.
Eliminationofotherlesswelldefinedfactorssuchasprotein
deficiencyandfoodtoxinsmaybeconsideredinsome
populations.Thesemeasuresshouldbefullyintegratedinto
othercommunity-basedprogrammesforthepreventionof
non-communicablediseases(e.g.,coronaryheartdisease).
TABLE3 Self-care
:Acrucialelementinsecondarypreventionis
selfcare.Thatis,thediabeticshouldtakeamajor
responsibilityforhisowncarewithmedicalguidance-e.g
adherencetodietanddrugregimens,examination
othis
ownurineandwherepossiblebloodglucosemonitoringset
administrationofinsulin,abstinencefromalcon
maintenanceofoptimumweight,attendingperio
check-ups,recognitionofsymptomsassociatedwt
glycosuriaandhypoglycaemia,etc.
TheWHOrecommendationsfor
thediagnosticcriteriafordiabetes(2019)
Measurement Diagnosticcut-offvalue
Fastingvenousorcapillary*
plasmaglucose
27.0mmol/L
(126mg/dL)
211.1mol/L2-hourpost-loadvenous
plasmaglucose (200mg/dL)
Table4showssomeoftheindividualinterventions
diabeteswithevidenceofefficacy.
212.2mmol/L2-hourpost-loadcapillary**
plasmaglucose (220mg/dL)
Homebloodglucosemonitoring:Assessmentofcont
hasbeengreatlyaidedbytherecentfacilityofimmealai
reasonablyaccurate,capillarybloodglucosemeasutoct
eitherbyoneofthemanymetersnowavailable
orthea
readingHaemoglukoteststrips(21).
Randomplasmaglucose 211.1mmol/L
(200mg/dL)
HbA1c* 6.5%(48mmol/mol)
Overnightfastof8-14hours.
Iflaboratorymeasurementisnotavailable,pointofcare,
"fingerstick")devicescanbeused(theyreportglucosevalues
incapillaryplasma).
**
Plasmaglucoseispreferredinpeoplewithsymptomswhoare
suspectedofhavingtype1diabetes
Thepatientshouldcarryanidentificationcardotails
nisname,address,telephonenumber(ifany)andthea
oftreatmentheisreceiving.Inshort,hemus
have
of
a
workingknowledgeofdiabetes.Allthese
mean
educasof
patientsandtheirfamiliestooptimizetheetfectivenes
primaryhealthcareservices.
Source:(1)

95. 449
VISUALIMPAIRMENTANDBLINDNESS
standardofpersonalandcommunityhygiene,
and
inadequatehealthcareservices.
TABLE
1
CausesofblindnessinIndia
2015-19Nationalsurveyonblindness)
Changingconceptsineyehealthcare
active
error
akia
uncorrected
ract
untreated
ractsurgical
complications
homatouscornealopacity
rachomatouscornealopacity
0.1percent
1.7percent
66.2percent
Recentyearshavewitnessedachangefromacute
intervention(cure)typicalofclinical
ophthalmologyto
Comprehensiveeye-healthcarewhichincludesthe
folloOwing
concepts:
7.2percent
0.8percent
7.4
percent
2.8
percent
5.5
percent
1.2per
cent|
0.7percent
5.9percent
0.5percent
1.Primaryeyecare
Oneofthemostsignificantdevelopmentsinthefieldofeye
healthcareoverthelastfewyearshasbeentheconceptor
primaryeyecare,thatis,theinclusionofaneye-care
componentinprimaryhealthcaresystem.Theideaofprimary
eyecare,asoneofthemainingredientsofaprimaryhealth
careapproachtoblindness,hasrapidlygainedacceptancethe
Worldover.Itistodayrecognizedasamodelforeyecareatthe
communitylevel.Thepromotionandprotectionofeyehealth,
togetherwithon-the-spottreatmentforthecommonesteye
diseases,areitscornerstones.Thefinalobjectiveofprimary
eyecareistoincreasethecoverageandqualityofeyehealth
carethroughprimaryhealthcareapproachandthereby
improvetheutilizationofexistingresources.
isis
icoma
etic
retinopathy
erposterior
segmentdisease
therglobe/CNSabnormalities
rce:(10)
etinopathyofprematurity(ROP)isemergingasan
rtantcauseofchildhoodblindness.Withtheadventof
rbaricoxygenandopeningoflargenumberofprivate
governmnetNICUs,thesurvivalofthepremature
ies
(bornbefore30weeksofgestationand1500grams
eightatbirth)hasimprovedconsiderably.Thesebabies
atriskofdevelopingROPandthereisdirenecessityto
teawarenessnotonlyinpublicbutalsoamongst
nalmologistsandpaediatricianstodetectandtreatROP
2.Epidemiologicalapproach
Theepidemiologicalapproachwhichinvolvesstudiesat
thepopulationlevelhasbeenrecognized.Itfocuses,among
otherthings,onthemeasurementoftheincidence,
prevalenceofdiseasesandtheirriskfactors.Thelocal
epidemiologicalsituationwilldeterminetheactionneeded.
me.
demiologicaldeterminants
a)AGE:About30percentoftheblindinIndiaaresaid
se
theireyesightbeforetheyreachtheageof20years,
manyundertheageof5years.Refractiveerror,
homa,conjunctivitisandmalnutrition(vitaminA
ciency)areimportantcausesofblindnessamong
aren
andtheyoungeragegroups;cataract,refractive
,
glauecomaanddiabetesarecausesofblindnessin
dleage;accidentsandinjuriescanoccurinallage
ps,
butmoreimportantlyintheagegroup20to40
rs.(b]SEX:Ahigherprevalenceofblindnessisreported
malesthaninmalesinIndia.Thishasbeenattributedto
gherprevalenceoftrachoma,conjunctivitisandcataract
ngfemalesthaninmales(12).(c)MALNUTRITION:
nutritionasacauseofblindnesswashardlyrecognizeda
yearsago.Itiscloselyrelatednotonlywithlowvitamin
ntake,butalsowithinfectiousdiseasesofchildhood
eciallymeaslesanddiarrhoea(whichprecipitate
uition.
Inmanycasesproteinenergymalnutrition
is
alsoassociatedwithblindness.Severeblinding
1ealdestructionduetovitaminAdeficiency(e.9
omalacia)islargelylimitedtothefirst4-6yearsoflife
epeciallyfrequentamongthose6monthsto3years
e.fd)OccUPATION:Ithaslongbeenrecognizedthat
workinginfactories,workshopsandcottage
dre
pronetoeyeinjuriesbecauseofexposureto
airborneparticles,flyingobjects,gases,fumes,
nusuallyweldingflash),electricalflash,etc.Many
includingdoctorsareknowntohavedeveloped
re
cataractswhileexposedtoX-rays,ultravioletrays
Waves,(e)SOCIALCLASS:Thereisaclose
nshipbetween
3.Teamconcept
Inmanydevelopingcountries,thereisonlyoneeye
specialistformorethanamillionpeople.Increasingly,
therefore,healthcareleansontheuseofauxiliaryhealth
personneltofillmanygaps.InIndiathisgapisfilledby
villagehealthworkers,ophthalmicassistants,multi-purpose
workers,andvoluntaryagencies.
4.Establishmentofnationalprogrammes
Anotherimportantdevelopmentinconnectionwiththe
preventionofblindnesshasbeentheestablishmentof
nationalprogrammes.Manyoftheseprogrammeswerefirst
startedbyvoluntaryagenciesconcernedwithblindness
prevention(e.g.,eyecamps)andsomeofthemfocusedona
singledisease,suchastrachoma.Theincreasingrecognition
oftheprimaryhealthcareapproachtoblindnessresultedin
comprehensivenationalprogrammesforthepreventionof
blindness(13)fromallcauses.
Preventionofblindness
Theconceptofavoidableblindness(i.e.,preventable
orcurableblindness)hasgainedincreasingrecognition
duringrecentyears.Agreatmanyotthecausesofblindness
lendthemselvestopreventionand/orcontrol
-
whetherby
improvingnutrition,bytreatingcasesofintectiousdiseases,
orbycontrollingtheorganismswhichcauseinfection,orby
improvingsatetyconditionsparticularlyontheroads,at
workorinthehome(14).
omicstatus.
Surveysindicatethatblindnessis
Thecomponentsforactioninnationalprogrammesfor
thepreventionofblindnesscomprisethefollowing:
theincidenceofblindnessandsocio-
eyesight
ecauseofmeddlesomeophthalmologyby
cks
nebasicsocialfactorsareignorance,poverty,oW
more
prevalentinthe
0-do(12),.(6)SOCIALFACTORS:Manypeoplelose
poorerclassesthaninthe
.INITIALASSESSMENT
Thefirststepistoassessthemagnitude,
geographic
distributionandcausesofblindnesswithinthecountryor

96. ACCIDENTSANDINJURIES 455
numberofaccidental
deaths
INDIA
Table3
showsthereported
es
inIndia.
by
main
causes
In2017,218,876deathsduetoroadinjuríesoccurredin
ndia,withanage-standardizeddeathrateforroadinjuries
O
.2deathsper100,000population,whichwasmucn
nigherinmales(25.7deathsper100,000)thaninfemales
(8.5deathsper100,000).Thenumberofdeathsduetoroad
njuriesinIndiaincreasedby58.7percentfrom1990to
Z017,buttheage-standardizeddeathratedecreased
Slightly,by9.2percent.In2017,pedestríansaccountedtor
6,729(35.1percent)ofalldeathsduetoroadinjuries,
motorcyclistsaccountedfor67,524(30.9percent),motor
vehicleoccupantsaccountedfor57,802(26.4percent),and
cyclistsaccountedfor15,324(7.0percent).Indiahada
higherage-standardizeddeathrateforroadinjuryamong
motorcyclists(4.9deathsper100,000population)and
cyclists(1.2deathsper100,000population)thantheglobal
average.Roadinjurywastheleadingcauseofdeathin
malesaged15to39yearsinIndiain2017,andthesecond
leadingcauseinthisagegroupforbothsexescombined.
Theoverallage-standardizeddeathrateforroadinjuries
variedbyupto2.6timesbetweenstatesin2017.Wide
variationswereseenbetweenthestatesinthepercentage
changeinage-standardizeddeathrateforroadinjuriesfrom
1990to2017,rangingfromareductionof38.2percentin
Delhitoanincreaseof17.0percentinOdisha.Ifthetrends
estimatedupto20
IndiaoverallwouldachievetheSDG2020targetin2020,or
evenin2030(12).
TABLE
33
Renortednumberofacciderntaldeathsin
Indiabymaincause(2014-2015)
No.ofDeaths
Cause
2014
2015
20,201
10,510Natural
calamity
Unnatural
causes
Collapseof
structures
4,31,556 4,02,947
1,821
1,885
Drowning 29,903
29,822
Electrocution 9,606 9,986
Explosions 194 831
Falls 15,399 16,759
Factory/Machineaccidents 797 695
Fire 19,513 17,700
Firearms 633 736
Suddendeaths 26,526 35,023
Killedbyanimals 886 951
Minesorquarrydisaster 210 118
22,587 26,173Poisoning
Stampede
weretocontinue,nostateinIndia,or
178 480
Suffocation 1255 1,427
Trafficaccidents 1,62,107 1,77.423
Riskfactors(11)
Othercauses 11,375 6,774
Causesnotknown 21,551 15,165 Speed
Anincreaseinaveragespeedisdirectlyrelatedbothto
thelikelihoodofacrashoccurringandtotheseverityofthe
consequencesofthecrash.Someotherfactsareasbelow.
Total(Natural+Unnatural) 4,51,757 4,13,457
Source:(9)
Pedestrianshavea90%chanceofsurvivingacarcrash
at30km/horbelow,butlessthana50%chanceof
survivinganimpactof45km/horabove.
30km/hspeedzonescanreducetheriskofacrashand
arerecommendedinareaswherevulnerableroadusers
arecommon(e.g.residentialareas,aroundschools).
TYPESOFACCIDENTS
preolop
1.
Roadtrafficaccidents
nmanycountries,motorvehicleaccidentsrankfirst
ainongallfatalaccidents.Everyyearalmost1.25million
peoplediefromroadaccidentsintheworld.Inaddition,for
every
death,thereareasmanyas20-50non-fatalinjuries
and10-20
seriousinjuriesrequiringlongperiodsot
epensivecare,nursingandtreatment.Roadtrafficfatalities
rate
ishigherin
younger
agegroups.Childrenandyoung
peopleundertheageof25
years
accountforover30per
OTthosekilledandinjuredinroadaccidents(10,11)
Apartfromreducingroadtrafficinjuries,loweraverage
trafficspeedscanhaveotherpositiveeffectsonhealth
outcomes(e.g.byreducingrespiratoryproblems
associatedwithcaremissions).
Drink-driving
Drinkinganddrivingincreasesboththeriskofacrash
andthelikelihoodthatdeathorseriousinjurywillresult.
Theriskofbeinginvolvedinacrashincreases
significantlyaboveabloodalcoholconcentration(BAC)
of0.04g/d
LawsthatestablishBACsof0.05g/dlorbeloware
effectiveatreducingthenumberofalcohol-related
crashes
Enforcingsobrietycheck-pointsandrandombreath
testing
can
leadtoreductionsinalcohol-relatedcrashes
byabout20%,andhaveshowntobeverycost-effective.
From
oungage,malesaremorelikelytobeinvolved
d
trafficcrashesthanfemales.AmongyoungdriverS,
to
belii
neageof25yearsarealmost3timesaslikely
Killedinacarcrashasyoungfemales(
Vulnerahi
Nearly
4
percent)ofthosedyingonroadsare
le
roaduserslikepedestrians,
cyclistsana
sTS.Comparedtocarsthe
two-wheelersare
accidond.
sta
andprovidelittleprotectionfortheirriders
in
equently
involved
inaccident
aevelopedcountries,fourwheelersaremore
centdeathsthatresultfromroadtraffic
and
middle-incomecountries.
Even
peoplefromlowersocio
morelikelytobe
involvedin
Motorcyclehelmets
Wearingamotorcyclehelmetcorrectlycanreducethe
riskofdeathbyalmost40%andtheriskofsevereinjuryy
byover70%.
ore
than
90perceraccidents
Din
high-incom
countries,
occur
inlow
onomic
backgrounds
are0adtraffic
accidents
(11).

97. 460
NON-COMMUNICABLE DISEASES
devices
toaddressprescriptionofappropriateassistivedevicesto
physicalandsensoryimpairments;
musclestrengtheningandbalanceretraining
prese
byatrainedhealthprofessional;
fro
of
mus
body
a
rubule
3.Donotapplyicebecauseitdeepenstheinjury.
4.Avoidprolongedcoolingwithwaterbecauseitmaylead
tohypothermia.
5.Donotopenblistersuntiltopicalantimicrobialscanbe
applied,byahealth-careprovider. Poisoning
Early
6.Donotapplyanymaterialdirectlytothewoundasit
mightbecomeinfected.
Poisoningwasresponsibleforanestimated2500
deathsduringtheyear2008worldwide.InIndia0
about
28,012poisoningdeathswerereportedduringthe
7.Avoidapplicationoftopicalmedicationuntilthepatient
hasbeenplacedunderappropriatemedicalcare.
year
2010(20).Themostcommonagentsresponsible
tor
poisoningarepesticides,kerosene,prescriptiondrugs
and
householdchemicals.Pesticidesarewidelyusedin
many
Falls
countrieswhereagricultureisanimportantpartof
tha
economy.ReportsfromIndia,Indonesia,SriLankaa
Thailandindicatethatcommonavailabilityanduseoftoxic
pesticidesisresponsibleforintentionalandunintentionsl
Globally,fallsareamajorpublichealthproblem.An
estimated646,000fatalfallsoccureachyear,makingitthe
secondleadingcauseofunintentionalinjurydeath,after
roadtraffticinjuries.Thoughnotfatal37.3millionfallsare
severeenoughtorequiremedicalattention.Suchfallsare
responsiblefor17millionDALYslost.Over80%offall-
relatedfatalitiesoccurinlowandmiddle-incomecountries,
withregionsoftheWesternPacificandSouthEastAsia
accountingformorethantwo-thirdsofthesedeaths.Inall
regionsoftheworld,deathratesarehighestamongadults
overtheageof65years(18)
Fallsareresponsibleforthelargestnumberofhospital
visitsfornon-fatalinjuries,especiallyforchildrenandyoung
adults.Fallsfromrooftops,balconies,windowsandstair
casesarecommon.FactorsspecifictoSEARcountriesare
fallsfromtreesofworkerspickingfruitsorcoconuts,tapping
toddy,childrenfallingfromrooftopswhileflyingkites,high
incidenceoffallsamongconstructionandforestryworkers.
Aslifeexpetancyincreasesinthesecountries,theincidence
ofhipandotherfracturesduetofallamongtheelderlyare
alsoassuminggreaterproportions(19)
Someoftheriskfactorsinclude(18)
occupationsatelevatedheightsorotherhazardous
workingconditions;
morbidityandmortality.
InSriLanka,pesticidesareoneofthemainagentsused
inattemptedsuicideinruralareas.The
useof
organophosphorousinsecticidesinsuicideeventshas
heon
reportedtobeashighas20-30percent.
Paraquat
intoxication
isknowntocauseirreversibledamagein
patients.Manycountriesalsoreportaccidentalingestionof
keroseneasaleadingcauseofpoisoning,especiallyamong
children(19).AstudyfromThailandrevealedthat54
per
centofcasesofpoisoningamongpre-schoolchildren
bite
involvedtherapeuticdrugs.
Snakebite
Snakebiteisaneglectedpublichealthissueinmany
tropicalandsubtropicalcountries.About5millionsnake
bitesoccureachyear,resultinginupto2.4million
envenomings(poisoningfromsnakebites)atleast94,000-
125,000deathsandaround400,000amputationsand
other
permanentdisabilities.MostoftheseoccurinAfrica,Asia
andLatinAmerica.InAfricaalonethereareanestimated
1millionsnakebitesannuallywithabouthalfneeding
treatment.Thistypeofinjuryisoftenfoundamong
women
childrenandfarmersinpoorruralcommunitiesinlowand
middle-incomecountries(21).
alcoholorsubstanceuse;
sOcio-economicfactors
overcrowdedhousing,youngmaternalage;
includingpoverty,
Theoutcomeofsnakebitedependsonnumerous
factors,
includingthespeciesofsnake,theareaofthebody
bittern
theamountofvenominjected,andthehealthcondition
ot
thevictim.Feelingsofterrorandpanicarecommonate
snakebiteandcanproduceacharacteristicsetofsymptoO
mediatedbytheautonomicnervoussystem,suchasa
tachycardiaandnausea.Bitesfromnon-venomoussnak
canalsocauseinjury,oftenduetolacerationscausedbytne
snake'steeth,orfromaresultinginfection.
Abite
may
ai
triggerananaphylacticreaction,whichispotentiallyfae
First-aidrecommendationsforbitedependsonthesnar
underlyingmedicalconditions,suchasneurological,
cardiacorotherdisablingconditions
side-effectsofmedication,physicalinactivityandloss
ofbalance,particularlyamongolderpeople;
unsafeenvironments,particularlyforthosewithpoor
balanceandlimitedvision
Prevention(18)
Forchildren,effectiveinterventionsincludemultifaceted
communityprogrammes;engineeringmodificationsof
nurseryfurniture,playgroundequipment,andother
products;andlegislationfortheuseofwindowguard
Forolderindividuals,fallpreventionprogrammescan
includeanumberofcomponentstoidentifyandmodifyrisk,
suchas:
ted
inhabitingtheregion,aseffectivetreatmentforbiteininc
bysomespeciescanbeineffectiveforothers.
Thevenomofpoisonous
predominantly
causesnakesmaybe
neurotoxicorpredominantlycytolytic.Neurotoxins
respiratoryparalysisandcytolyticvenomscauseo
destructionbydigestionandhaemorrhage
authescreeningwithinlivingenvironmentsforrisksforfalls;
clinicalinterventionstoidentifyriskfactors,suchas
medicationreviewandmodification,treatmentoflow
bloodpressure,VitaminDandcalciumsupplementation,
treatmentofcorrectablevisualimpairment;
haemolysisanddestructionoftheendotheliallininge
rattlesnake
bloodvessels.Themanifestationsof
envenomationaremostlylocalpain,redness,swenate
and
nausea,andvomiting,hypotensionand
coagu
toss
mayextravasationofblood.Perioraltingling,merai
allic
homeassessmentandenvironmentalmodificationfor
alsooccur.Neurotoxicenvenomationmaycauamitted
dysphagia,diplopia,andrespiratoryfailure.
ven
em
thosewithknownriskfactorsorahistoryoffalling

98. of cobras,almostallviperscause
necrosis
461ACCIDENTSANDINJURIES
from
m
some
Muscletissuesbegintodiethroughout
the
morethan2yearsold,0.5mg/kg,maximum2mg/k
day)canbegivenevery4-6hoursbymouthasrequired
notaspirinornon-steroidalanti-inflammatory
drugs
whichcancausebleeding).
of
muscle
tissue.
leadstoacuterenalfailure.body
and
itresultsin ulationofmyoglobin
intherenal
bules
which
Early
clue
utesthatapatienthassevere
envenoming(22):
a
jdentifiedasaverydangerousone;
Antivenomifthepatient
fulfilscriteriaforantivenomn
Teatmentand
ifthenecessaryskills,equipment,
antivenom,adrenalineandother
necessarydrugs
are
available,giveantivenom.Theseskillsincludeabilityto
agnoselocalandsystemic
envenoming,setup
ntravenousinfusionorintravenous
injection,identity
neearlysignsofanaphylaxisandtreatitwith
intramuscularadrenaline.Re-asessforrepeateddose(5)
ofantivenom.
Ifnoantivenomisavailable,transtertoa
hospital.
apid
the
bite;
earlyextensionoflocalswellingfromthesiteof
arly
tenderenlargemenoflocallymphnodes,
indica
icatingspreadofvenominthelymphaticsystem;
Farlysystemicsymptoms:collapse(hypotension,shock),
vomiting,diarrhoea,severeheadache,nausea,
saviness"oftheeyelids,inappropriate(pathological)
drowsinessorearlyptosis/ophthalmoplegia;
Earlyspontaneoussystemicbleeding;
Passage
ofdarkbrown/blackurine.
.the
patientisinshock/hypotensivegivecautious
Intravenousfluidchallenge(adult250-500mlof0.9%
saline)tocorrecthypovolaemicshock.
6.
f
thepatienthasevidenceofrespiratoryparalysisgive
Oxygenbymask,consideratropineandneostigmine
andtransfertoahospital.
Itisassumedthatassisted
ventilationotherthanbyatight-fittingfacemask
connectedtoananaesthetic(Ambu)bagwillnotbe
possibleatthislevel.
MANAGEMENT ATCOMMUNITY OR
VILLAGELEVEL(23)
A.
First-aid
TheGovernmentofIndiadevelopedanationalsnake
hiteprotocolin2007whichincludesfollowingadvice:
1Reassure
thepatient.70%ofallsnakebitesarefrom
non-venomousspecies.Only50%ofbitesbyvenomous
speciesactuallyenvenomatethepatient;
2.Immobilizeinthesamewayasafracturedlimb.Use
bandagesorclothtoholdthesplints,nottoblockthe
bloodsupplyorapplypressure.Donotapplyany
compressionintheformoftightligatures,theydon't
workandcanbedangerous;
3.Donotgivealcoholicbeveragesorstimulants.Theyare
knownvasodilatorsandtheyspeeduptheabsorptionof
7.Ifthepatientisoliguric
management
8.Thebitewound:ifnecrotic,tamperedwith(incisions
etc.)orobviouslyseptic,giveantibioticsandtetanus
prophylaxis.
initiateconservative
9.Assesstheneedandfeasibilityoftransportingthepatient
toahigherlevelofthehealthservice(seeAabove)
especiallyincaseof
a.Substantialbleeding,20WBCTstillpositive(non-
clotting)6hoursafterinitialantivenomdose
b.Progressiveparalysis(muscleweakness)orrespiratory
difficulty
C.Reducedurineoutputvenom;
4.Removeanyitemsorclothingswhichmayconstrictthe
bittenlimbifitswells(rings,bracelets,watches,
footwear,etc.);
d.Anaphylaxisunresponsivetoadrenaline
e.Shock/hypotensionunresponsivetofluids
f.Severelocalnecrosisorsignssuggestiveof
5.Donotinciseormanipulatethebittensite.Donotapply
ice;and
compartmentsyndrome
10.Discouragetheuseofineffectiveandpotentiallyharmful
drugs(e.g.corticosteroids,antihistamines,andheparin).
6.Transportthepatienttoamedicalfacultyfordefinitive
treatment.
C.AttheDistrictHospital(23)
B.AttheRuralClinic,Dispensary,HealthPost,
orPrimaryHealthCentre
ProceedasinBaboveplus:
1.Assessmentcarryoutamoredetailedclinicaland
assessmentincludingbiochemicaland
haematologicalmeasurements,ECGorradiography,as
1.Assessforsignsoflocalandsystemicenvenoming:carry
Outasimplemedicalassessmentincludinghistoryand
simplephysicalexaminationlocalswelling,painful
tenderenlargedlocallymphglands,persistentbleeding
fromthebitewound,bloodpressure,pulserate,
bleeding(gums,nose,vomit,stoolorurine),levelof
consciousness,droopingeyelids(ptosis)andothersigns
ofparalysis.Monitorthesesignshourly.
2.Check:20minutewholebloodclottingtest(20WBCT),
urineexamination(appearance,stickstestingforblood
etc.).Identifythesnakeoraphotoofit(ifbrought).
indicated.
2.Antiuvenom:ifnoantivenomisavailable,transfertoa
hospitalthathasantivenomortreatconservatively;this
mayrequiretransfusionofbloodorfreshfrozenplasma.
3.Analgesia(seeBabove)and,ifrequired,consider
strongerparenteralopioiddrugsasrequired,allwith
greatcaution(e.g.subcutanous,intramuscularoreven
intravenouspethidine,initialadultdose50-100
mg
children1-1.5mg/kg;ormorphine,initialadultdose
5-10mg;children0.03-0.05mg/kg,).
4.Ifthepatienthasevidenceoflocalnecrosis(gangrene)
givetetanustoxoidbooster,antibioticsanddosurgical
debridementofdeadtissue.
naigesiagiveanalgesiabymouthifrequired:
Paracetamol(acetaminophen)(adultdose500mgto1g
ldXimum,4gin24hours;children10-15mg/kg,
aximum100mg/kg/day)orcodeinephosphate(adult
Ose30-60mg,maximum240mgin24hours;children

99. 462 NON-COMMUNICAB1.E DISEASES
www.m
Thoughreliableestimatestorworkrelatedinjuries
deathsintheRegionarenotavailable,partlu and
5fthepatienthasevidenceofbulbarorrespiratory
paralysisinsertendotrachealtube,laryngealmask
airwayori-gelaiway.Ifthereisevidenceofrespiratory
failure,assistventilationmanuallybyanaesthetic
(Ambu)bagormechanicalventilator
6.Ifthepatienthasevidenceofacutekidneyinjury:treat
withperitonealdialysis.Ifthisisnotavailable,transferto
aspecializedhospital.
7.Ifthepatientisbleedingseverelyorisalreadyseriously
anaemiccross-matchandtransfuse.
majorityoftheworkersareemployedin
organized
thatnearlyoneper
towide
deathsand10percentotpermanentimpairmentrestulof
agriculturalinjuries.AgricultureworkersareexposedtOm
varietyofphysical,chemicalsticide
andfertili:
sectors,fewstudiesindicate
biological(animalbitesandanimalrelatediniurioer,
mechanicalinjuries.Theestimatesfromagriciult
re
nd
injury
varyfrom22-29per1000workers.Theincidence
rate
Indiaisestimated
to
116per100,000workers.Inastudypopulationof23.000
ruralHaryana,nearly31percentoftheinjurieswere
n
toagriculturalactivity(24).Ofthese,seriousinjuries
causedbymechanizedequipmentandtractors(19)
Rapidindustrializationhasalsoresultedinmortalituan.
morbidityofmanyworkersinhazardousindustries.
injuryamongagricultureworkersin
8.Rehabilitation:encourageexercisingofbittenlimb.
D.AttheReferral(Specialized)Hospital(23)
ProceedasinBandCaboveplus
were
1.Moreadvancedsurgicalmanagementoflocalnecrosis
(e.g.splitskingrafting).
2.Moreadvancedinvestigationsincludingbacterial
culturesandimaging(CTscans)asindicated.
3.Ifthepatienthasevidenceofacuterenalfailure
peritonealorhaemodialysisorhaemofiltration.
Theuniquefeaturescommontotheworkplace
inthis
regionarethatthemanuallabourcontentishigh
and
tho
man-machineinteraction
1Sunsafe.Inaddition,there
is
greateremphasisonattemptsfo,changetheworker's
behaviour,butdesignsthatprovideautomaticprotection
ate
ignored.Childrenandpeoplewhoarechallengedphysicallu
aswellasmentallyareatagreaterriskotencountering
Occupationalinjuries(19).
4.Implementrehabilitationbyphysiotherapists.
Strengtheningofhealthsysteminmanagingsnakebite
Toreducecomplicationsanddeathsfromsnakebites,
healthsystemsneedtobeimprovedatvariouslevels.The
governmentmustdevelopapolicyforsnakebite,makingita
notitiabledisease,developingasnakebiteprogrammethat
includesstandardtreatmentguidelines,trainingofhealth
personnelandensureanadequatesupply,distributionand
storageofgoodqualityantivenom.
4.Railwayaccidents
Withtheincreaseinnumberoftrainsand
passengers,
the
increaseinthenumberofaccidentsandcasualtiesresulting
therefromisnotunexpected.During2010,about
30,576
peoplediedofrailwayaccidentsinIndia
(9)The
main
factorinvolvedinrailwayaccidentsishumanfailure.
ANTIVENOM (22)
5.Violence
Untiltheadventofantivenom,bitesfromsomespeciesof
snakewerealmostuniversallyfatal.Despitehugeadvances
sin
emergencytherapy,antivenomisoftenstilltheonly
effectivetreatmentforenvenomation.Thefirstantivenom
wasdevelopedin1895byFrenchphysicianAlbertCalmette
forthetreatmentofIndiancobrabites.Antivenomismade
byinjectingasmallamountofvenomintoananimal
(usuallyahorseor
sheep)toinitiateanimmunesystem
responseTheresultingantibodiesarethenharvestedfrom
theanimal'sblood.
Antivenomisinjectedintothepersonintravenously,and
worksbybindingto,andneutralizingvenomenzymes.It
cannotundodamagealreadycausedbyvenom,so
antivenomtreatmentshouldbesoughtassoonaspossible.
Modernantivenomsareusuallypolyvalent,makingthem
effectiveagainstthevenomofnumeroussnakespecies.
Homicideandcollectiveviolenceaccountforaround
10%ofglobal,injury-relateddeath.In2016,therewere
an
estimated477,000murders.Fourfifthsofhomicidevictims
aremen,and60%ofvictims,males.
andmiddle-incomecountriesoftheRegionofthe
Americas
hasthemosthomicides,with28.5per100,000population,
whilethelowestmurderrate,almost14timeslower(2.1
per
100,000population),isfoundinthelow-andmiddle
incomecountriesofTheWesternPacificRegion(25
Violenceisreportedtobeincreasingrapidly.ltalsofollow
thesameepidemiologicalpatternasanyotherdisease(host,
agentandenvironment),i.e.amotivated
personwho
injures;asuitabletarget;andasuitableenvironment
ortne
absenceofaguardian,allcoincidingintimneand
space
Often,itmayonlybepossibletoinitiatestepsforprevention
afteranepisodeofviolencehasalreadytakeniplace
Someoftheriskfactorsforviolentbehaviour
are
(9
ze1544Thelow
Pharmaceuticalcompanieswhichproduceantivenom
targettheirproductsagainstthespeciesnativetoa
particulararea.Althoughsomepeoplemaydevelopserious
adversereactionstoantivenom,suchasanaphylaxis,in
emergencysituationsthisisusuallytreatableandhencethe
benefitoutweighsthepotentialconsequencesofnotusing
antivenom.
Exposuretoviolenceandsocietalacceptability
or
Violenceasameanstosolveproblems.Theimage
or
violenceasanacceptableand
effectivetoolfor
solving
problems,whether
acrossinternationalborders,
o
thestreet,oraroundthehome,
mayspilloverinto
rea
behaviour;
Availabilityoflethal
Significantlyincreasesthepossibilityof.bothfataland
non-fatalinjuries;
Consumptionofalcoholandotherdrugs15n
linked
almost2/3ofcasesofviolenceaccordingtO
studies.11
3.Industrialaccidents
weaponslikefire-arms
Thereareapproximately580millionworkersinthe
South-EastAsiaRegion.Approximately60-80percentof
theseworkersareemployedinagriculture,fisheries,home
industries,andsmall-scaleunits.Injuriesduetothese
occupationsresultinanestimated120millioninjuriesand
200,000deathsperyear(19).
to
veral

100. 4750
NATIONAL.LPROSY"ERADICAION"PROGHAM.
Implementation
Supervisionself-carepractices
SupervisionuseofMCR
Supervisionofulcer&dressing
carriedoutbypatient
Referral
Neuritis
Villagehealth
&
sanitation
committee
(GKS)
ASHA,PAL Reaction
Disability
Ulcer
Implementation
Referral
Self-careadvice
Reaction
AdvicetoRCScases
Monitoring&supervisionof
ASHAactivities.
SubCentre Disability
Neuritis
FollowW-up -Ulcer
L
SectorPHC
Implementation
Managereactions
Ulcerdressing/technologytransfer
IdentifyorreferpatientneedingRCS
SupplyMCRfoot-weartoneedypatient
Advice
toreconstructivesurgerycases
Advisetoselfcare
Referral
Leprareactionsdifficulttomanage
Complicatedulcer
-Eyeproblems
Reconstructivesurgerycases
BlockPHC
PersonsneedingGr-lfoot-wear
Follow-upofRCS,Leprareaction
Counselling
mplementation
Managementofcomplicated
ulcers
Managementoflepra
Referral
DistrictHospitall
apexgroup
Referdifficult
9ulcercases
Referfor
reactions
ScreeningcasesforRCS
Diagnosisofdifficultto
diagnosecases/relapsecase
skinsmear/RCS
reconstructive
surgery
Implementation Referral
anagementoflepra
reactionsS
Supplyoffoot-wear
Referfor
reconstructive
surgery/follow-
upofRCS.
District
Nucleus
Reconstructive
SurgeryCentre
mplementation
Referral
Implementation
Reconstructivesurgery/amputation/RCStraining
Follow-upafterreconstructivesurgery
Supplyoffoot-weartodistrictnucleus.
15
FIG.1
SOuTçe{12) ReferralSysteminNLEP

101. NATIONALTBELIMINATION
PROGRAMME 477
into
thebasicproblemsofleprosyisalsopartof
Reseasofthe
NLEP.Thisismainlycarriedoutinthe
ent
sector,viz.tnecentral
JALMAInstituteof
treatmenttoincreasethetreatmentcompletionrates.supply
ofdrugswasalso
strengthenedtoprovideassuredsupplyot
arugstomeetthe
requirements.ofthesystem(16).
Theobjectivesofthe
RNTCPare:ernmeAOraandtheCentralLeprosyTeachingand
Pn
Instituteathingeipu,Cnennaisupportedby
gional
TrainingandReierrallnstitutesatAska(Orissa),
.Achievementofatleast85percent
curerateof
Intectiouscasesof
tuberculosis,throughDOTSinvoiving
peripheralhealthfunctionaries;and
or(Chhattisgarh)andGouripur(WestBengal).
apur
EP
Agencies
The
InternationalFederationof
Anti-LeprosyAssociation
activelyinvolvedaspartnerinNLEP
InIndia,ILEPis
nstitutedby10
agencIesviz.ineLeprosyMission,Damien
oundationofIndiaIrust,NetherlandLeprosyRelief,
GormanLeprosyKelietAssociation,LepraIndia,ALES,
AIFO.Fontilles-India,AEKF-IndiaandAmericanLeprosy
Mission.ILEP
1sprovidingsupportinihe1ormofplanning,
onitoringandsupervision
o1theprogramme.capacity
buildingofgeneralhealthcarestaif,EC,
providingre-
2.
Augmentationofcasefindingactivities
throughquality
sputummicroscopy
todetectatleast70percent
or
estimatedcases.
Therevisedstrategywasintroducedinthe
coOuntryin
a
phased
manner.TheRNTCPhasexpandedrapidly
overthne
yearsandsinceMarch2006.,itcoversthewhole
country.
he
RNICPhasnowenteredintoit'ssecondphaseinwhich
the
programmeaimstoconsolidatethegainsmade
todate,
Towide
servicesintermsof
activitiesandaccessandto
sustaintheachievements.ThenewinitiativesandthewIder
collaborationwithothersectorsaimtoprovidestandardized
treatmentand
diagnosticfacilitiestoallTBpatients
irrespectiveofthehealthcarefacilityfromwhichtheyseek
ireatment.TheRNTCPalsoenvisagesimproved
accessto
marginalized
groupssuchasurban
slumdwellersandtribal
groupsetc.
surgeryservicesandsocio-economic
constructivee
rehabilitationofpersonsaifectedwith
eprosy.36NGOs
conductingre-constructivesurgeriesfordisabilitycorrection
inleprosyafected
personsarealsosupporiedbyILEP(1).
NonGovernimentOrganizationshavebeeninvolvedin
theprograrmmeformanydecadesandhaveprovided
valuablecontribulioninreducingtheburdenofleprosy.
Presently.54NGOsaregetting
gran-in-aid
from
GovernmentofIndiaunder
SETscheme.NGOsservein
RNTCPisbuiltuponinfrastructurealready
establishedby
thepreviousnational
tuberculosis
programme,while
incorporatingtheelementsoftheinternationally
recommendedDOTS.
remote,inaccessibleareas,urban
sluims.industrial/labour
populationandothermarginalizedpopulafiongroups.IEC,
preventionofdisability,casedetectionandrelerral,and
follow-upfortreatmentcompletionaresomeimportant
activitiestakenupbyNGOs(1),.
DOTSstrategyadoptedbyRevisedNationalTBControl
Programmeinitiallyhadthefollowingfivemain
componcnts:
1.Politicalwilland
administrativecommitment.
TheleprosysceneinIndia
ispassingthroughan
impoitantphaseoffransition
-fromahighburden
country
leprosytoa
relativelylowburdencounty,fromapariially3.Adequatesupplyofqualityassuredshortcourse
erucal
programmetoamoreintegraied
one,om
programmeaimedatincreasein
coverage1orcposy4.
Directlyobservedtreatment.
Ces
looneofsustainingquality
services,
anaiom
Enralizationtodecentralization(15).
2.Diagnosisbyqualityassuredsputumsmearmicroscopy.
chemotherapydrugs.
5.
Systematicmonitoringand
accountability.
WHO hasannounced
Global
LeprosyStrategy
2020:
"Acceleratingtowordsaleprosy-freeworia1o
er
reducingthediseaseburdenduetoleprosy.
PiCase
Telertopage358fordelails.
In2006,STOPTBstrategywasannouncedbyWHOand
adoptedbyRNTCPThe
componentsareasfollows:
-PursuingqualityDOTS-expansionandenhancement.
Addressing
TB/HIVand
MDR-TB.
Contributingtohealthsystemstrengthening.
Engaging
allcareproviders.
LNATIONALTB
ELIMINATION
PROGRAMME
-Empowering
patientsand
communities.
Enablingandpromotingresearch(diagnosis,treatment,
onal
TuberculosisProgramme
(NTP)hasbeenin
ralion
since1962.However,the
treatmentsuccessa
remai
cepiablylowandthedeathanddefault
rales
throshigh.Spreadof
multidrugresistant
was
Eingtofurtherworsenthesifuation.
vaccine).
Manyoftheinitiativeslikedevelopingand
pilotingthe
feasibilityofNationalAirborneIntectionControlGuidelines,
developingand
piloting
strategyfor
"PracticalApproachto
LungHealth'aretheexamplesofinitiativestakenbyRNTCP
underthe
comprehensive
strategyofSToP
TB(16).
In2014,theWorldHealth
Assemblyunanimously
approved
toend
globalIBepidemicby"End
TB
Strategy",
a20year
programmewithvisionofaworldwith
zerodeath,diseaseand
sulteringduetoTB.Fordetails
please
retertopage233.
Inview
ofEnd
TBtargets,the
programmehas
been
renamedfromKevisedNational
TuberculosisContr
Programme
(RNTCP)toNational
luberculosis
Elimination
R,
inorderto
overcometheselacunae,he
VeTnmentofIndiadecidedtogivea
newthrust
toTB
omint
esby
revitalizingtheNTPwiththe
assistance
control
activities
by
oncies.Theulated,
Teatment
Internaogramme
(RNTCP)thus
formulated,adoplea
Ttne
nort-core
ecommended
Directly
Observed
Treatment
CoS1-effSe{DOTS)strategy,asthe
most
systemauca
Os1-eifective
approa
nment,toensurethe
provisionof
organizedand
10
revitalize
the
TBcontrol
Politicaland
administrative
rammeinIndia
Smear
Bcontrolservices
wasobtained.
Adopuon
ecedin
Py
1orreliableandearly
diagnosis
was
es,DT
decentralizedmannerinthe
generalneal
Owas
adoptedasastralegyio
rovision
of
Programme
(NTEP).
wwwwwe.wmwwiw
wwwwww

102. 478
HEALTHPROGRAMMES ININDIA
NTEPOrganogram(17)
the
accountabletothestategovernment,technicallyfollou
instructionsoftheCTD,andcoordinateswithCTD heNTEPstructurecomprisesoffivelevels:National,state,
district,sub-districtandperipheralhealthinstitutionlevelsas
showninFig.2(17).
districts,andisassistedbyotherchnical&secretarial
stalf.
StateTBcellisbeingsupportedbyStateTBTrainina:
DemonstrationCentre(STDC)inmanystatesthroucht
threeunits-atrainingunit,supervisionandmonitorines
andanIntermediateReferenceLaboratory(IRL)
supporting
Nationallevel
CentralTBDivision(CTD)managestheNationalTB
ControlProgrammefortheentirecountryatthecentrallevel
underAS&DG(RNTCP&NACO)throughanational
programmemanager,DeputyDirectorGeneralTB(DDG
TB).Thefinancialandadministrativecontrolofthe
programeismanagedbytheJointSecretaryfromthe
administrativearmoftheMoHFW.
aneffectivequalityassurancesystemofthesputumsmea
microscopynetworkandlaborataryservicesforPM
(molecularDRtestingandC&DST)intheState.Operation
ResearchisalsoacomponentofSTDC.
EachstatealsohasonefullyoperationalStateDrugStoro
(SDS)foreach5croreofpopulation.It
isresponsiblefor
effectivemanagementofmedicinesandotherlogistics,and
ensuringuninterruptedsupplyofgoodquality1st&2ndlino
anti-TBmedicinesforadultsandpaediatricpopulation.
tional
TheCTDissupportedbyaNationalTBInstitute(NTI)
Bengaluru,sixNationalReferenceLaboratories(NRL)
includingNTI,NationalInstitutefor
Tuberculosis(NIRT),Chennai,NationalInstituteof
TuberculosisandRespiratoryDiseases(NITRD),Delhi,
NationalJapaneseLeprosyMissionforAsia(JALMA),
InstituteforLeprosyandothermycobacterialdiseases,Agra,
RegionalMedicalResearchCentre,Bhubaneshwarand
BhopalMemorialHospital&ResearchCentre(BMHRC),
Bhopal.TheCTDisalsosupportedbyNationalTaskForce
forcolaborationofMedicalColiegesactivitiesinthecountry
throughZTF/STE
Researchin
Districtlevel
Thekeylevelforthemanagementofprimaryhealthcare
servicesisthedistrict.TheChiefDistrictHealthOfice
(CDHO)/ChiefDistrictMedicalOfficer(CDM0)/Civil
Surgeonoranequivalentfunctionaryinthedistrictis
responsibleforallmedicalandpublichealthactivities
includingcontrolofTB.TheDistrict.TuberculosisCentre
(DTC)isthenodalpointforTBcontrolactivitiesinthe
district.Afull-timeDistrictTuberculosisOfficer(DTO),
trainedatnationallevel&basedattheDTC,isresponsible
forplanning,training,supervisingandmonitoring
the
programmeinthedistrict.DTOisassistedbyothertechnical
&secretarialstaff.Theprimaryroleofthe
DTCisa
managerialone.
Variouscommitteesofexpertstoguidetheprogrammeat
differentlevelsontechnical&policymattersarethere
supportingCentralTBDivision.
StateLevel
Thestateshavetotalownershipandaccountabilityfor
the
TBcontrolintheirstate.Statehealthsocietyorits
equivalentunderNationalHealthMissionofthestate
managestheTBcontrolprogramme.Afull-timeState
TuberculosisOfficer(STO),trainedatnationalleveland
basedattheStateTBCell(STC),isresponsibleforplanning,
training,supervisingandmonitoringtheprogrammeinall
thedistrictsoftheirrespectivestates.STOisadministratively
Sub-DistrictLevel(TuberculosisUnitLevel)
IntegratingtheTBcontrolprogrammewiththehealth
systemincreaseseffectivenesandefficiencyofTBcareand
control.India'sTBcontrolprogrammehas
been
mainstreamedefficientlywithNationalHealthMission
(NHM).
AmajororganizationalchangeinNTEPisthecreationof
asub-districtlevel(TuberculosisUnit-TU).TheTUisthe
nodalpointforTBcontrolactivitiesinthe
sub-district.
TUS
arebasedmainlyinNHMhealthblockswiththeoveralal
toalignwithNHMBlockProgrammeManagementu
(BPMU)foroptimumresourceutilizationandappropria
monitoring.InurbanareastheTUshavebeencreatedbaseu
onapopulationof
1per2,00,000(range1.5-2.5lak
torruralandurbanpopulationand
1
per1,00,000.
.26
lakh)populationinhilly/tribal/difficult
areas.
TuberculosisUnit(TU)consistsofa:designatedMet
OfficerTuberculosisControl
(MO-TC),as'wellasonee
timesupervisorystaff
-SeniorTreatmentSupervIsor
iowever,OneSeniorTBLaboratorySupervisor(SIL
continuetobein5lakhpopulation(onepe
populationfortribal/hilly/difficultareas).Thereisa
ision
ofadditionalSTSifmorethan300TBcasesare
reghan
publicsectorannuallyinaTU;ditional
STSif
more,tha
50privatehealthestablishmentsareregisterea from
inaTUandmorethan200TBpatients
arenotie
theseprivatehealthestablishmentsannually,ina
TheBlockMedicalOfficeralsofunctions
asa
edical
MinistryofHealth&
FamilyWelfare
Supportingfacilities
-NationalInstitutes(3)
NationalReference
Laboratories(6)
CentralTBDivision
IntermediateReference
StateTBCell
Laboratories(29)
StateTBTrainingand
Demonstration
37
states/UTs
DistrictTBCentre
767Districts
Centre(26)
CultureandDST
Laboratories(42)
TBUnit
Oneper1.5-2.5lakhpopulation
NodalDR-TB
Centre(154)
CBNAAT
Laboratories(1180)
DesignatedMicroscopyCentre
50,000to
1Lakhpopulation
PeripheralHealthInstitute
OfficerTBControl(MO-TC).Fortheurban
medicalofficerfromthehealthfacilitywhere DHOo
shouldbedesignated,incoordinat
with
CM&HOD
ocated
TunctionasaMO-TC.AllMO:TCsshouldbetrained
NTEP
FIG2
OrganizationstructureofNTEP
Source:(17)

103. wwwwww
479
state
level
instilution.
Bnibility
ofmanagemeniof1BControlProgrammeat
MOTChastheoverall
sevEn
daysinaonth.TheteamolSTSandSTLSare
100,000
population
(50,0iniribal,desert,remoteand
esponsi
the
TU
Thenain
functionsofIRlsaremonitaring
oflaberatory
$ervices
acrossthestateand
maintenance
ititsquality
throughexternalguality
assurance.Thereare27[Ris
withfacilitiesforculture&DSTusing
Phenotypie(5olid
&LiquidCultureMGIT)and
(ernatypic
fechnology(LPA&
CBNAATI.
and
isexpectedtondertakesupervisaryvisitsfor
the
administrativesupervisionoltheMO-TCandthe
DTO.The
TUwillhaveoneMicroscopyCentreforevery
ppu
Llluregions)reterredtoasthe
DesignatedMicroscopy
entic
(DMC.however,1orcompletegeographiccoverage
National
programmeenvisages1o
expandsputumsmear
CBNAATsites
eraict
Inadditiontotheculture
DSTlaboratories.
CBNAAT
centresarealso
establishedto
diagnose
Rifampicin
resistance
amongailTBpatients
(Universal
DST}.Usualiy
theseare
establishedin
DTCs.TBunitsand
medicai
colleges.Thecountryisinthe
processofexpanding
CBNAATsite
network.Theyalsoservetodiagnose
TB
amongpresumptiveTBcasesfromkeypopulation
microscoPy
serviceafPHClevel).MicroscopyCentresmay
Jrug
tks
alsobe
establishedbeyondpopulationnormsinMedical
colleges,
corporatehospitals,ESIC,railways,NGOs,private
hospitals,etc.
sbes.;
PeripheralHealth
Institutions(PHIs)
Forthepurposeof
NTEP,aPHlisahealthfacilitywhich
is
mannedbyatleastamedicalofficer.Atthislevel,there
are
dispensaries,PlHCs,CHCs,referralhospitals,major
hospitals.specialityclinicsorhospitals
(includingother
health
facilities),TBhospitals,ARTCentresandmedical
collegeswithintherespectivedistrict.
Allhealth
facilitiesin
theprivateandNGOsectorsparticipatinginNTEParealso
consideredasPHlsbythe
programme.SomeofthesePHIs
alsofunctionas
DMCs.Peripheralhealthinstitution
undertaketuberculosiscase-findingand
treatmentactivities
asapartofthegeneralhealthservices.
Insituationswhere
morethanoneMOispostedinanyoftheperipheralhealth
centres,oneofthemmaybe
identifiedandentrustedwith
theresponsibilitiesoftheNTEPThereis
1TBHealthVisitor
(TBHV)peronelakhurbanpopulationtosupporttheurban
TBcontrolactivities(17).
alion. DRTBCentres(17)
Jth
Cilz
DMO:CR
disticts
DRTBCentresare
specialized
centresforclinicai
managementofdrugresistant
TB.At
state/regionaldivision
level,thereareNodal
DRTBCentres
({NDRTBC).tomanage
seriously
illDRTBcases,
DRTBwithextensiveresistanceand
DRTBcasestobetreated
vwithregimescontaining
newdrugs
(Bedaquilineand
Delamanid)
actra
ities
ina
DTC
respoisite
itoring
&
ertecxe
DTC
Atthedistrictlevel.therearedistrict
DRTBcentres
(DDRTBC),tomanage
DRTBcaseswith
MDRTB,andH
mono/polyresistance.Thesecentreswilifunctionunderthe
guidanceof
NDRTBCs.
C.Atthecentralleveltherearesix
designatedNational
Reference
Laboratories(NRLsnamelyNational
TuberculosisInstitute,
Bengaluru,Nationalinstitutefor
Researchin
Tuberculosis
(NIRT),Chennai.National
Instituteof
Tuberculosisand
RespiratoryDiseases
(NITRD),Delhi.National
JALMAinstitute.Agra,
RegionalMedicalResearchCentre,
Bhubaneshwarand
Bhopal
MemorialHospital&ResearchCentre
(BMHRC),
Bhopal.
NIRTChennaiisalsoaSupraNational
ReferenceLab
(SNRL)forWoridHealth
Organization
(WHO)fortheSouthEastAsiaRegion.NTIiaWHO
collaboratingcentrefortraining.whileNITRDisWHO
centreofexcellenceinTBlaboratoryservces.The
NRL3
aremainlyresponsibletorexternalqualityassurarceof
Labnetwork,drugresistance
surveiliance,wainingand
TBlaboratoryservices
(17)
thehee Theservicesofthelaboratoryareutilizedfordiagnosing
TB&DR-TBcasesandformonitoringoftreatmentofthese
patients.Thelaboratorynetworkunder
NTEPisa3-tier
Systemforprovisionofdiagnosticservicesand
maintaining
itsquality.
TB
care
hase
lth
Miss
e
TUst
distria
overala
ementUapprapree
realed
bes&
A.Theperipherallaboratoriesaresituatedinthepublic
sectorlikethe
dispensaries,
PHCs,CHCs,referral
nospitals,major
hospitals,specialty
clinics/othersector
hospitals/TB
hospitals/medical
collegesandinthe
private/NGOsectors.For
establishmentofmicroscopy
centreinalab,itmusthave
adequate
physical
rastructure,BinoculermicroscopeandatrainedLi.
neselaboratoriesarecoveredunderquality
assurance
research.
NTEPendorsed
TBdiagnostics
(1}
1.Smearmicroscopyforacidfastbacilli.
mechanisms
.Someofthelabsnothaving
facllityfor
s]putum
nicroscopy,functionasasputum
collectioncenires,
nd
suchfacilitiesarealso
establishedinareassuch
asS
inetribal,hilly,desertand
difficulttoreach
areasof
necountryforimprovingthe
accessfodiagnostic
a.SputumsmearstainedwithZeihl-Neelsenstaining;or
b.
Fluoresencestainsandexaminedunderdirector
indirectmicroscopywithorwithoutLED
Wed
Medie2
CA
leas
as
onei
VISOr
(S/3
ST
2.Culture
a.Solid(LowensteinJansen}media;or
Services.
b.Liquidmedia
{MicddleBrook)usingmanualsemi
automaticorautomaticmachines,e.g.,Bactec,MGIT
ver
2.5
BiR
n
addition,largehospitalsand
medical
collegeshave
i
esof
digital
X-Ray,rapid
molecular
test
artridgebased
nucleicacid
amplificationtest
BNAAT&LineProbe
Assay-LPA),FineNeedle
piration
Cytology
(FNAC),
histopathology,and
Culture&DSTfordiagnosticservicesolTB
estatelevelanodal
laboratory
is
designatedas
mediate
reference
laboratory
(IRL)which
isusuay
ted
inthe
StateTB
Trainingand
Demonslration
re(STDC)/medical
college/publichealth
laboratory.
Isa
prove
EIsere
oe
etc.
3.Rapiddiagnosticmoleculartest
a,
ConventionalPCRbasedLineProbeAssayforMTB
complex;or
oed
b.
Real-timePCRbasedNucieicAcidAmplificationTest
NAATforMTBcomplex,e.g.GeneXpert.
a
10
TB
Un
4
Radiographywhereavailable.
5
Tuberculinskintest.
BHO

104. 480
HEALTHPROGRAMMES ININDIA
NewInitiatives
re
themselveswithsymptomssuspiciousoftuberculosis
screenedthrough2sputumsmearexaminatiöns.Sputu
1.NIKSHAY:TBsurveillanceusingcasebasedweb
basedITsystem(18)
microscopicexaminationisdoneindesignatedRNT
microscopycentres.TheyarelocatedeitherintheCH
PHC,TalukaHospitalsorintheTBdispensary.Eachcentre
CentralTBDivisionincollaborationwithNational
InformaticsCentrehasundertakentheinitiativetodevelopa
casebasedwebbasedapplicationnamedNikshay.Theword
iscombinationoftwoHindiwordsNIandKSHAY,meaning
eradicationofTB.
hasaskilledtechniciantoensurequalitycontrol,asenior
T
laboratorysupervisorisappointedforevery5microscon
centres.TheseniorTBlaboratorysupervisorrechecksallthe
positiveslidesand10percentofthenegativeslidesofthero
fivemicroscopycentres.Thustheerror:indiagnosina
a
patientisminimized.Itisessentialtoexamine2sputum
specimensofeachpatientbeforeaconclusivediagnosis
can
ThissoftwarewaslaunchedinMay2012andhas
followingfunctionalcomponents.
Mastermanagement
Userdetails
bemade.Onesputumsampleisnotsufficientfordiagnogs
asthechanceofdetectingsmearpositivecaseisonly80per
cent.Sputummicroscopynotonlycontirmsthe
diagnosis.
butalsoindicatesthedegreeofinfectivityandresponse
to
showsthecriteríaof
TBpatientregistrationanddetailsofdiagnosis,DOT
provider,HIVstatus,follow-up,contacttracing,outcomes.
treatment.
DetailsofsolidandliquidcultureandDST,LPA,
CBNAATdetails.
ig.1onpagenumber
diagnosisandinitiationoftreatment.
DR-TBpatientregistrationwithdetails.
Referralandtransferofpatients.
PrivatehealthfacilityregistrationandTBnotification.
MobileapplicationforTBnotification.
SMSalertstopatientsonregistration.
SMSalertstoprogrammeofficers.
Automatedperiodicreports:
a.Casefinding
b.Sputumconversion
Allpatientsareprovidedshort-coursechemotherapyfree
ofcharge.Duringtheintensivephaseof.chemotherapyall
thedrugsareadministeredunderdirectsupervision.called
DirectObservedTherapyShort-term(DOTS).DOTSisa
communitybasedtuberculosistreatmentand
carestrategy
whichcombinesthebenefitsofsupervisedtreatment,and
thebenefitsofcommunitybasedcareandsupport.t
ensures
highcureratesthroughitsthreecomponents:appropriate
medicaltreatment,supervisionandmotivationbyahealthor
non-healthworker,andmonitoringofdisease
statusbythe
healthservices.DOTSisgivenbyperipheralhealthstaffsuch
asMPWs,orthroughvoluntaryworkerssuchasteachers,
anganwadiworkers,dais,ex-patients,socialworkersetc
TheyareknownasDOT'Agent'andpaidincentive'
honorariumofRs150perpatientcompletingthetreatment
C.Treatmentoutcome.
TheprogrammehasstartedusingITenabledadherence
toolslike99DOTSforHIV-TBpatients.Thiswillbe
expandedtoallTBpatientswithimplementationofdaily
regimen(7)
2TBNotification
Newerinitiatives
(11)
1.DailyregimenforpaediatricTB:Inordertotransition
thecountrytotheupdatedguidelinesforpaediatrie
treatmentintheSTCI,whichfollowthecurrentWHO
dosingguidelines,thegovernmenthasdecidedto
introduceadailydosingregimenusingchild-trienuy
fixeddosagecombinations(FDCs).Theprocurement
ot
anti-TBdrugsindailyfixeddosecombination(FDG)has
beeninitiated.TreatmentwithFDCsofantiTbdrugs
w
bein
sixweightbandsforpaediatricpatients
Anoptio
for
familymemberstoprovide.Directly0bservec
Treatment(DOT)topaediatricpatientshasbeen
incorporatedinthe
guidelines.
2DailyregimenforallformsofTBinthecountry.
3.PilotsforuniversalaccesstoTBcases.
4Universaldrugsusceptibilitytesting(DST)pa0
rapidmoleculardiagnosticshavebeenscaled
up
too
CBNAAT,
diagnosisofdrugresistantTBservices:Nearly5op
centotallnotifiedTBcaseswereoffereduniversal
aru
SUSceptibilitytestingin3rdquarterof2019.
5ShorterregimenandBedaquilineIn2018snot
egimenandBedaquilinefortreatmentotairFrom
Bpatients,havebeenexpandedinthecountryrro
2018,
morethan46,129DR-TBpatientshaves
initiatedonshorterregimenand7,973DRBpe
onnewerdrugcontainingregimen.
:Campaignmode-Active
casefindingTo
reaco
unreached,the
programmehas
carriedoutsyste
nordertoensureproperdiagnosisandmanagementof
TB
cases,
andtoreduceTBtransmissionandtheemergernce
andspreadofMDRTB,it
isessentialtohavecomplete
informationofallTBcases.AccordingtotheGovernmentof
hIndia
nötification:dated7thMay2012,itisnowmandatory
forallhealthcareproviderstonotify
everyTBcasetolocal
authoritiesi.eDistrictHealthOfficer/ChiefMedicalOfficer
of
adistrictandMunicipalhealthofficer,everymonthina
givenformat(19).
3BanonTBSerologyi
Theserologicaltestsarebasedonantibodyresponse,
whichis
highlyvariableinTBand
mayreflectremote
infectionratherthanactivedisease.Currentlyavailable
serologicaltestsarehavingpoorspeciticityandshouldnot
beusedforthediagnosisofpulmonaryorextra-pulmonary
TB.Theirimport,manufacturing,sale,distributionanduse
isbannedbytheGovernmentofIndia(18)
coveringalldistrictsfor
decentralized
4.Directbenefittransferschemes
Directbeneficiarytransfersystemsarebeingestablished
bylinkingTBpatientsreportedin
NI
andPEMStoeffectivelydeliverbenefitstoTBpatientsand
theirproviders(7).
SHAYwithAADHAR
he
Initiationoftreatment
Earlyidentilicationofpeoplewithhighprobabilityof
havingactiveTB(presumptiveTB)isthemostimportant
activityofthecasefindingstrategy.Patientspresenting
activeTBscreeningamonghighrisk
populationsthtol
lation,
housevisitsortargetedsettingvisit(tribalpoP

105. MANAGEMENT OFDRUGRESISTANTTB481,
agehomesprisons,
orphanages,
transitcamps
slums,old
etc.)Theampaignwas
edbasedonburdenofTB,casefindingefforts,HIV
conducted
inprioritydistricts
beddedtertiarycarefacilityestablishedtoserveapopulation
ofapproximately10million,withanairborneinfectioncontrol
compliantward,facilitiesforpretreatmentevaluations,
treatmentinitiations,follow-upmonitoringandmanagement
ofadversedrugreactions,preventionandreliefofphysicaland
socialsufferingcausedbythediseaseanditstreatment,
complicationsandco-morbidities.Alltheseactivitiesare
supportedbytheprogrammestaffinadditiontohaving
counsellingforpatientsandundertakingdatamanagement.
By2017,147DR-TBCswereestablishedacrossIndia,
designatedasNodalDR-TBcentre,oneforapproximately
every10millionpopulation,includingsomeinprivate
nstitutespartneringwithRNTCPAbout5to10districtsare
attachedtoeachcentre.DR-TBpatientsareadmittedfora
shortperiodandoncestabilizedontreatment,discharged
withadvanceintimationtothedistrictsandreferredbackto
theirdistrictsforcontinuationandcompletionoftreatment.
DuringtreatmenttheyarereferredbacktoDR-TBCsfor
changeofregimensandmanagementofadversereactions.
TRanddrugresistantTBintherespectivedistricts(7).
Thedrugsaresuppliedinpatient-wiseboxes
containing
thesllcourseoftreatment,
andpackagedinblisterpacks.rtheintensivephase,eachblisterpack
containsoneday'smedication.Forthecontinuationphase,eachblisterpackntainsoneweekssupplyof
medication.Thecombipack
drugsforextensionor
intensivephasearesupplied
icion
separately.
he
bOxesarecolouredaccordingtotheeategoryoftheregimen,redforcategoryI
patients,bluefor
ase'is
oty
categoryllpatients.
yand
"estyr
Ors
îhe.
cit
Paediatrictuberculosis
Pleaserefertopage218fordetails.
chenohep
Drugresistancesurveillance(DRS)under
NTEP(2014-2016)(16)
TheprevalenceofdrugresistancetoTBcanbetakenas
anindicatoroftheeffectivenessoftheTBcontrolactivities
overaperiodoftimeand,therefore,RNTCPhastakensteps
tomeasurethisimportantindicator.
chemoteeA
OTS).
DUTS
andcaxe
soxon
edteatmet,
Todecentralizethepretreatmentevaluation,treatment
initiationofRR.TBorHmono/polyDR-TBandfollow-up
processes,twodistincttypesofDR-TBCswillbeestablished.
TheexistingnodalDR-TBcentre(NDR-TBC)willcontinue
forapproximately10millionpopulation.OneDistrictDR-TB
centre(DDR-TBC)willbeestablishedforeverydistrict.
Someofthestateshavealreadyestablishedthesecentres.
suppont
tesa
nents:
apprsz4
ationboy
TheaimofDRSistodeterminetheprevalenceof
antimycobacterialdrugresistanceamongnewsputumsmear
positivepulmonarytuberculosis(PTB)patients,andalso
amongst previouslytreatedsputumsmearpositivePTB
patients.Drug-resistantTBhasfrequentlybeenencountered
inIndia,anditspresencehasbeenknownvirtuallyfromthe
timeanti-TBdrugswereintroducedforthe
treatment
ofTB.
zalhealth
sadse
such
&6taca
Theadvantagesofdecentralized"testandtreat
approach"are(20):
ocialuodhes
dpaidinesa
ingtheterxr
Earlyandfasterinitiationoftreatmentofalldiagnosed
DR-TBpatients;
Bringingcareclosertotheresidenceofmajorityofthe
DR-TBpatients;
ToobtainamorepreciseestimateofMulti-DrugResistant
TB(MDR-TB)burdeninthecountry,RNTCPcarriedout
drugresistancesurveillance(DRS)surveys(2014-2016)in
accordancewithglobalguidelinesinselectedstates.The
Significantreductionincatastrophicexpenditure
includinglossofworkhoursandfamilyincome;
Rationallyminimizingtheneedanddurationfor
hospitalization;
Minimizingtravelofpatients,therebytransmissionrisks
duringtravels;
Accountabilityofthedistrictprogrammemanagement
units;and
ordertotresiresultsofthesesurveysindicateprevalenceofMDR-TBtobe
about2.84percentinnewcasesand11.60percentin
retreatmentcases(17)
esforpuae*
the
curett
K
has
derde
ng
chil:es
e
procuenett
inationjA
ant-lb
cas
afienis.Atg
MANAGEMENT OFDRUGRESISTANTTB
Theservicesforqualitydiagnosisandtreatmentofdrug
resistantTBcaseswereinitiatedin2007inGujaratand
Maharashtra.Theseservicessincethenhavebeenscaledup
àndcurrentlytheseservicesareavailableacrossthe
COuntryfromMarch2013.Forfulldetailsaboutthepatient
regimens,pleaserefertopage219.
RationalizingutilizationofexistingDR-TBCstoenable
themtoconcentrateinmorecomplexclinicaldecisions
andensuringqualityassuranceoftreatmentand
research.
rectly
Ciere
enis
haske
1.DistrictDR-TBcentre(20)
State-levelstructureandresponsibilities(20)
Whileanationalexperttechnicalworkinggrouphas
developed
nationalpolicies,technicalandoperational
guidelines,thestate-leveliswherethemajorityofplanning
ac
S,
implementationandmonitoringoccur.Thestate
Committee isresponsiblefordevelopingtheplanof
action
forimplementation,
ervision,monitoringandqualityenhancementofPMD
Services
intherespectivestate.
TheDDR-TBC isresponsiblefortheinitiationand
managementofuncomplicatedDR-TBpatientslikeRR-TB
orHmono/polyDR-TBinadistrict,notonlyoninpatient
basis,butalsoonoutpatientbasis,whereveradvisableand
possible.TheDDR-TBCcanbeestablishedatinstitutesina
certainorderofpreference,namely,medicalcolleges,district
hospitals,
institutes/othersectorhospitalswiththeavailability
of
requiredclinicalexpertise.
Couniy
Ezpanst
decentalat
TB
maintenance,
hospitalsandNGO/private/corporate
expansion,
NeanfyP
2.NodalDR-TBcentre(20)
Patientswithadditionalresistancetosecond-linedrugs,
drugintolerance,contraindications,failingregimen,patients
returningaftertreatmentinterruption
of>1month,
emergenceofanyexclusioncriteriaforstandardregimenfor
RR-TBor
mycobacterium(NTMs)andthoseneedingpalliativecare
wouldbemanagedatNDR-TBC.
Drug-resistanttuberculosiscentre(20
ogrammaticandclinical
managementofDR-TB
1S
eftex
butfeasiblewhenthehealthsystemisstrengthenedto
eltectivelyintegrate
whatisnecessary
onttalizedandresistantTBisnotcompletelyoason
nfact,clinica
of
drg
e,.counui
DRIBp
mono/polyDR-TBBH
regimen,non-TB
Carendized
carefortheentireduration.
Infact,clinical
Tesourea epresenceofaclinicalandpatient
supportexpert
centre.ThisistheDR-TBCentre,whichisa20-30

106. HEALTHPROGRAMMES ININDIA
TherequirementsfortheNDR-TBcentreareasfollows:
Shouldpreferablybeatertiarycareinstitute;
Separatewardformaleandfemalepatientsshouldbe
availablewithatleast10bedsineach;
Sar
careservicedeliveryinIndia.AsperNational
Seek
SurveyOrganizationreport,about70percentpatientee
careinprivateclinicsandhospitals(21).
Delaysindiagnosis,over-diagnosisofTBdueto
an.
Over.
dependenceonX-rays,theuseofmultiplenon-stanAllPMDTservices(beds,investigations,ECGand
ancillarydrugsformanagementofadversedru1g
reactions)tobeprovidedfreeofcosttothepatient;
Relevantspecialtiesincludingrespiratorymedicine,
generamedicine,psychiatry,dermatology,ENT,
ophthalmology,
anaesthesiologistandcardiologistshouldbeavailable
directlyorthroughlinkages;
NDR-TBCcommitteetobeformed;
regimensforinappropriatedurations,thelackofamechaud
toensurefullcourseottreatmentandto
record
tro
outcomesaresomeissuesotconcernintheprivates
sector.te
Similarproblemsinvaryingdegreesareencounteredin
other
healthsectorsaswell.Theadvantagesand
disadvantages
od
gynaecology, paediatrician,
publicandprivatesectorareasshownbelow:
Publicsector Privatesector
Freediagnosis
Freetreatment
StandardizedregimenBetter
access
Referralandtransfer
system
Supervisionand
monitoring
Accountabilityof
treatmentoutcome
.Widechoices
(>5
lakhpractitioners)
Advantages
NationaltrainingofNDR-TBCcommitteemembers
(includingChairperson);
NationalAICguidelinestobeimplementedinDR-TB
wardsandoutpatientssetting.
Routineclinicallaboratoryinvestigationfacilitytobe
madeavailableforpretreatmentevaluationand
monitoring:
Ancillarydrugsshouldbeavailable;
ManagementofadversedrugreactionasperPMDT
guidelines;
Doctors,nursingandsupportstaffshouldbeavailable
fromtheinstitute;
-Convenienttiming5
Shorterdistances
Personalattention
andcare
Projecteddiscounts
Faithandperceptions
ofbettercare
DisadvantagesStaff'snon-responseCostof
clinical
to
symptomns
ST, DelaysbetweentestsCostofdiagnostic
examinationfees
tests
ReportsandrecordstobemaintainedforPMDT;and
Quarterlyreporttobesubmittedelectronically.
andreceiving
results Costofdrugs
Irrational3 Difficultyin
prescriptions
Infrequent
useof
quality
sputum
tests
tordiagnosisof
TB
No
adherence
tracking
mechanisms
transporting
TheoverallstructureandrolesofdifferentlevelofPMDT
T 7:
specimens
23 I
Financialexpenditure
ontravel,food,daily
necessities,extra
servicesaresummarizedinFig.3.
TBcareservicesintheprivatesector
medicines
PerceivedlowqualityFearof
losingpatient
ofservices
Theprivatesectoriseverythingoutsidetheambitofthe
Governmentrunpublichealthservices.
Itvarieswidelyinits
size,natureofservicedeliveryandthesocio-economic
groupsserved.
Itholdsafactualpredominanceofhealth
ifinvolvedin
RNTCP
Source:(21)
C&DST lab NodalDR-TBC Statedrug
store
Prepare&shipdrugboxestodistr
level
Maintainward&AlCmeasures
Receive
Dx/FUspecimens
Providerapidresultstodistrict,
FieldandDRTBcentre
Pre-treatmentevaluation
Managesupplychainfor
diagnosticsand
drug9s
StartM/XDRTBtreatment
Consultforcomplications
Clinicalexpertresource Maintain
records,
NIKSHAY&
DVDMS
Maintainrecords&NIKSHAY
Qualityassuranceofresults
Maintainrecords&NIKSHAY
DistrictDR-TBC
District
CBNAATlab
InitiatepatientonstandardDR-TB
regimen(MDR/RR-TB,
Hmono/polyDR-TBpatients)
ManageADR
MaintainrecordsandNIKSHAY
ldentify
suspects,refer
specimens
Coordinate
fortestresults
Referpatientsto
N/DDR-TBC
Coordinate
care&drug
flowirou
districtdrugstoreto
field
level
Maintainrecords,
NIKSHAY,
monitor&supervise
Diagnose
RR-TBpatientsatdistrict
level
Maintainrecords&
NIKSHAY
Field
Identifypresumptivecase,referspecimens
Support,supervise,manageDR-TBpatients
Communicateresultstopatients
Manageminoradverseeffects
Referpatientforthetreatmentinitiation
Collectandreferfollow-upspecimens
3
OverallPMDTstructureandrole
Source:
(20)

107. strategicvisionofRNTCPistolaydownguidelines
MANAGEMENT OFDRUGRESISTANTTB
TBcareincountry.Theunderlying
principlermsfor
483
The
NationalAlDSControlProgramme(NACP)and
RNICPhavetakenthepolicydecisiontoadoptisoniazia
prophylaxistherapy
(1PT)
asastrategyforpreventionot
BamongPLHIV.Theimplementationwillbeina
phasedmanner.
8.TheRNTCPhasprioritizedpresumptive
TBcasesamong
peoplelivingwithHIVfordiagnosisofTBand
Rifampicinresistancewithrapiddiagnostictoolshaving
highsensitivitye.g.XpertMTB/RIE
to
extendblicservicestoprivatelymanaged
s.Standar
torTBcareinIndia,mandatoryTB
NIKSHAY,banonserodiagnosticsareamong
tio
TBcareservicesinprivatesector.
ls
to
improve
toryools,however,arelimitedandpartnershipis
Programmestaff:
arvateprovidersmorethanprivateprovidersneed
shouldunderstandthatRNTCP
TCR
IVcoordination(22)
-o
theadventofthecollaborativeeffortsin2001
activitieshaveevolvedto
covermostofthe
mendationsasperthelatestWHOpolicystatement
in
2012.In2007,thefirstnationalframeworkforjoint
collaborativeactivitieswasdevelopedwhich
eda
differentialstrategyreflectiveoftheheterogeneity
HIVepidemic.Coordinated
TB-HIVinterventionswere
nentedincludingestablishmentofacoordinatingbody
ionalandstatelevel,dedicatedhumanresources,
ationofsurveillance,jointmonitoringandevaluation,
tybuildingand
operationalresearch.
implementationof
collaborativeTB/HIVactivities
follows:
The
treatmentguidelinesarediscussedindetailon
page231.
Tuberculosisinpregnancy
Pleaserefertopage225fordetails.
NationalStrategicPlan(2017-2025)for
TBElimination
TheNationalStrategicPlan(NSP)2017-2025forTB
eliminationbuildsonthesuccessoflastNSP.Itisathree
yearcostedplanandaneightyearstrategicdocument.It
providesgoalsandstrategiesforthecountry's
responseto
thediseaseduringtheperiod2017-2025tobringabout
SIgnificantchangesintheincidence,prevalenceand
mortalityofTB,andattaintheglobalEndTBtargetsfive
yearsaheadofSustainable
DevelopmentGoalofTBfree
India.TheVISIONisTB
freeIndiawithzerodeaths,
ensifiedTBcasefindinghasbeen
implemented
tionwideatallHIVtesting
centres(knownas
egratedcounsellingandtesting
centres,or
1CTCs),
dhasnowbeenextendedtoallARTcentres.
VtestingofTBpatientsisnowroutinethroughprovider
tiatedtestingand
counselling
(PITC),
implementedin
stateswiththeintensified
TB-HIVpackage.
diseaseand
povertyduetoTB(23).
Objectives:
Themain
objectivesofNPSare:
1.Findalldrugsensitive
TBanddrugresistant
TBcases
withanemphasisonreachingTBpatientsseekingcare
fromprivate
providers,and
undiagnosed
TBin
high-risk
populations.
2.
Initiateandsustainallpatientson
appropriate
anti-TB
treatmentwherevertheyseekcare,withpatient
friendly
systemsandsocial
support.
3.
Preventthe
emergenceofTBin
susceptible
populations.
4.
Buildand
strengthen
enabling
policies,
empowered
institutions,
additionalhuman
resourceswithenhanced
capacities,and
provideadequate
financial
resources.
TSonsfoundtobe
HIV-positiveare
eligibleforfreeHlIv
Teatanetworkof
antiretrovial
treatment
(ART)centres.
centresarelocatedinmedical
colleges,
mainly
aftedandoperatedbythestate
AIDScontrol
societies,
da
fewaresituatedwithinthe
facilitiesofprivateor
J0
partners.Asof
December
2017,there
were
0ARI
centresoperatinginthe
country,1120
link-ART
Tntresand158
link-ARTplus
centres.Ten
Regional
2ntresof
Excellenceprovide
second-line
ARTservices
PLHIV,and24centres
provide
secondline
ART(ART
IScentres).
HIV-infectedTBpatients
who
areon
oreaseinhibitorbased
secondline
ARTare
getting
doutin-basedTBtreatmentinplaceof
Ritampicin.
Icy
decisionhasbeen
takenby
National
Technical
OTkingGroupon
TB/HIV
collaborative
activities
WG
on
TB/HIV)to
expand
coverageof
whole
blood
prick
HIVscreening
testat
all
DMC
without
a
and-aloneorF-ICTC
OVIderinitiatedHIVtesting
and
counselling(PI
presumptive
TBcases
(TB
suspects)
is
now
olicy
Thekey
strategiesareas
follows:
1.Private
sector
engagement
2.
Activecasefinding
3.
Drug
resistant
TBcase
management
4.
Addressing
social
determinants
including
nutrition
5.
Robust
surveillance
system
6.
Community
engagementand
multi-sectoralapproach
Expected
outcome:
Theaimofthe
National
Strategic
Planisto
achieve
eliminationof
TBby2025.
Duringplan
period,
targetsfor
TBare:
a
high
HIV.prevalent
states/settings
Ihe
plementation
willbedone
ina
phased
manne,1.
80%
reductioninTB
incidence
(i.e.
reduction
from211
per
lakhto43per
lakh)
2.
90%
reductioninTB
mortality(i.e.
reduction
from32
per
lakhto3per
lakh
3.
0%
patient
having
catastrophic
expenditureduetoTB
New
comprehensively
deployed
interventionsare
requiredto
acceleratethe
rateof
declineof
incidenceof
TB
to
more
than
10-15
per
cent
annually.
The
requirementsof
moving
towards
TB
elimination
have
been
integratedinto
four
strategic
pillarsof
Detect-Ireat-Prevent-Build
(DTPB).
Startingwithhigh
prevalent
statesand
theninAand
InlowHlVprevalent
states/settings
HIV
testing
BcategorydistrictsinrestoftheHIV
testing
outinely
ldbe
remented
inthe
age-groupof
25-54
yearsin
low
HIV
nong
presumptive
TB
casess
prevalentdistricts
(C&D)at
places
where
there
ng
activities
to
be
specifically
amongHIV
infected
pregnant
womenandCO-located
TBand
HIVtesting
facilities.
drenlivingwithHIv.

108. 496
HEALTHPROGRAMMES ININDIA
deliveryfromPHto
Suo-centre andoutreac
(b)Deployingretiredmanpowertocarryouti
activities
inurban
slumsandunderserveddniza
servicesaredeficient,
(C)Mobilitysupportwhe
immunizationofficerasperstateplanformonitdIstie
supportivesupervision;(a)Keviewmeetingatthing
an
withthedistrictsatomontnyntervals,
(e)Trainingove
coldchainhandlers,mid-level
managers,rofANM
sessio
mandtoachieve
self-sufficiencyintheproductionof
vaccines.UniversalImmunizationProgrammewasstartedin
Indiain1985.
Ithastwovitalcomponents:immunizationof
pregnantwomenagainsttetanus,andimmunizationo
childrenintheirfirstyearoflifeagainstthesixEPT
targetdiseases.Iheaimwastoachieve100percent
COverageofpregnantwomenwith2dosesoftetanustoxO1d
(or
aboosterdose),andatleast85percentcOverageor
intantswith3doseseachofDPT,OPV,onedoseofBC
andonedoseofmeaslesvaccineby1990.Universal
immunizationwastirsttakenupin30selecteddistrictsand
catchmentareasof50MedicalCollegesinNovember1985.
Theprogrammenowcoversentirecountryandpracice
areasofallthe242Medicalcolleges,thuscreatingabasetor
widercoverage(39).A"TechnologyMissiononVaccinatiopn
andImmunizationofVulnerablePopulation,specialy
Childrenwassetuptocoverallaspectsoftheimmunization
activityfromresearchanddevelopmenttoactualdeliveryO
servicestothetargetpopulation(40).
mechanics
etc.;(1)Supportformobilization
ofchildren
immunizationsessionsitesbyASHA,
women
etc.;(g)Printingofimmunizationcards,monitorinep
coldchainchartvaccineinventorychartsetc.
Inaddition,centralgovernmentisSupportingin
sun
ofauto-disablesyringes,downsizingtheBCGvialfplles
dosesto10dosestoensurethatBCGvaccine
isaom
20
allimmunizationsessionSites,strengthening
maintenance
ofthecoldchainsysteminthe
stata.and
supplyotvaccinesandvacCinevan.
self-help
sheet
and
PULSEPOLIOIMMUNIZATION PROGRAMME
PulsePolioImmunizationProgrammewaslaunchedintha
countryintheyear1995.Underthisprogrammechildrer
underfiveyearsofagearegivenadditionaloralpoliodrop
inDecemberandJanuaryeveryyearonftixeddays,Fr
1999-2000,housetohousevaccinationofmissedchildre
wasalsointroduced.TheNILDsroundscoverapproximatel
172millionchildrenandSNIDSrounds
cover40-80millic
children.Inaddition,largescalemulti-districtmop-upshau
beenconducted(42).Asaresultonlyonecaseofpolio
w
reportedin2011inthemonth
ofdanuary.Ason25thF
2012,Indiawasremovedfromthelistofpolioendem
countries,andon27thMarch2014,Indiawascertified
polio-freecountry.Pleaseseepage242formoredetails.
Iheimmunizationservicesarebeingprovidedthroughthe
exIstinghealth
caredeliverysystem(i.e.,MCHcentres,
primaryhealthcentresandsubcentres,hospitals,dispensaries
andICDunits).There
isnoseparatecadreofstaftforEPI.Ihe
recommendedimmunizationscheduleisonpage134.
Althoughthetargetwas"universal"immunizationby
T990,
inpractice,nocountry,evenintheindustrialized
world,haseverachieved100percentimmunization
in
children.Universalimmunization
is,theretore,best
interpretedasimplyingtheidealthatnochildshouldbe
deniedimmunizationagainsttuberculosis,diphtheria,
whoopingcough,tetanus,polioandmeasles.
Itis,however,
generallyagreedthatwhenimmunization
coverage
reachesafigureof80percentormore,thendisease
transmissionpatternsaresoseverelydisruptedastoprovide
adegreeofprotectionevenfortheremainingchildrenwho
have
notbeenimmunized,becauseof"herdimmunity
41).It
isalsoimportantthatchildrenareimmunizedduring
the
firstyearoflifeandthatlevelsofimmunizationare
Sustained
sothateachnewgenerationisprotected.
SignificantachievementshavebeenmadeinIndia.Atthe
beginningoftheprogrammein1985-86,vaccinecoverage
rangedbetween29percentforBCGand41percent
toor
DPT.Bytheendof2018,coveragelevelshadgoneup
signiticantlytoabout90percentfortetanustoxoidfor
pregnantwomen,about92percentforBCG,89percentfor
DPT3doses,89percentforOPV3doses,89percentfor
HepB,,89percentforHib,and80percentforMCV2.Since
then,thereisasigniticantdeclineinthereportedincidence
ofthevaccinepreventablediseasesascomparedtotheir
incidencein1987,asshowninTable9.
INTRODUCTIONOFINACTIVATEDPOLIOVACCI
(IPV)
ThelastglobalcaseduetowPVtype-2wasreportea
AligarhinIndiain1999.Mostoftheglobalcases
due
VDPVs(97%)aswellasVAPP(40%)areduetotype-2
vi
Thisnecessitatesthediscontinuationoftheuseofty
componentfromOPV.PolioEndgameStrategicPlan
recommendsreplacingtOPVwithbOPV.However,this
therecentbirthcohortatthetimeofswitchatriskof
V
andwildpoliovirustype2duetosilent/ongoing
transma
ofVDPVtype-2andalsotopotentialleakageofwild
virustype-2incaseofaccidental/intendedleakage
o
virusfromalaboratory.Tomitigatethisrisk,inactivated
virusvaccinewasintroducedpriortothetOPV-bOPV:
inApril2016.AspartofthisPolioEndgameStrategy.
hasintroducedInactivatedPolioVaccine
(1PV)
30November2015.
ItisgivenasfractionalIPVof0.ln
asintradermalinjectionat6and14weeksoflite(6).
TABLE9
Declineinreportedvaccinepreventable
diseasestromyear1987to2018
INTRODUCTIONOFMEASLESVACCINESEC
OPPORTUNITY
1987 2018 Inordertoacceleratethereductionofmeasles
Disease
morbidityandmortality,secondopportunitytor
vaccination
isbeingimplemented.TheNationall
AdvisoryGrouponimmunizationrecommendedintre
of2nddoseofmeaslesvaccinetochildrenbetween
Poliomyelitis 28,257
Diphtheria 12,952 11,720
Pertussis
163,786 18,006
and10yearsofagethroughsupplementaryimm
activity(SIA)forstateswhereevaluatedcoverageo
ofmeaslesvaccinationislessthan80percent.In
sta
coverageotmeaslesvaccinationmorethan80
per
seconddoseofvaccine
willbegiventhroug
immunizationat16-24months(1).
NNT 11,849 181
Measles
247,519 20,815
Tostrengthenroutineimmunization,GovernmentofIndia
hasplannedtheStateProgrammeImplementationPlan(PIP)
partC.Itconsistsof:(a)Supportforalternatevaccine

109. 497
UNIVERSALIMMUNIZATIONPROGRAMME
nOct2017.
Itinvolvesintensivepreparatio
piementationandintegration
ofsessionsintoreguta
nmunizationmicroplans.Thefocusisanurbansiuare
aaistrictswithslowestprogressandcompletionofdue
OTDeneticiariesonthebasisofheadcountsurveys.ASOn
dan,Z018,numberofchildrenvaccinated
were
49.0
1a
numberofchildrenfullyvaccinatedwas12.0Z1akn
umoerofpregnantwomenvaccinatedwas10.05lakn
(
77
CTIONOFPENTAVALENT VACCINE
HepB
+Hib)
B.
alentvacCinecontainsfiveantigensi.e.,
phtheria,pertusis,tetanusandhaemophil
b
(Hib)
vaccine.
14thweeksasprimaryaose.
I
hevaccinehas
hepatitisBvaccines
intheimmunization
dDPorbirthdoseofhepatitisBandtwo
Pentavalentvaccineisgivat
le.
However,
birth
sesofDPTwillcontinueasbefore(6).
MEASLES-RUBELLA (MR)VACCINE
r
doses
he
WHOregionalgoalforSEARismeasleselimination
anarubella/congenitalrubellasyndromecontrol
byz040.
neMvaccineisbeingintroducedthroughcampaig
argetingaround41crorechildrenintheagegroup,o
months
to15yearsinphasedmanner(coveringl/STdo
eOta
populationofthecountry),followedby2doses
in
TOutineimmunizationat9-12monthsand16-24
montns,
replacingthemeaslesvaccine(7).
ally
Indiaintroducedpentavalentvaccineintwo
-Keralaand
TamilNadu.Presentlyitcoversthe
country.
onUCTIONOFJAPANESEENCEPHALITIS
CINE
ammewasintroducedin2006tocover104
districtsinphasedmanner,usingSA14-14-2vaccine,
MRcampaignwaslaunchedinFebruary2017from
States/UTs(Karnataka,TamilNadu,Goa,Lakshadweepand
Puducherry)where3.34crorechildrenwerevaccinated
againstthetargetof3.43crore,withacoverageof97percent.
ampaignhascompleted33statesandimmunized
32.36crorechildren(97.04percentofthetarget)(11).
rtedtrorChina.SingledoseofJEvaccinewasgiventoall
en
between
Ito15yearsoragethroughcampaigns(3).
Evaccineisbeingintegratedintoroutineimmunizationin
istrictswherecampaignnadalreadybeenconductedto
anize
thenewcohortofchildrenbyvaccinatingwithtwo
sat9-12monthsand16-24months(1).
highburdendistrictshavebeenidentifiedinAssam,
PradeshandWestBengalforadultJEvaccination
inPNEUMOCOCCAL VACCINE(PCV)
ge
groupof15-65years.Thiswillcutdowndeathsand
bidityduetoJEinadultsaswell(6).
PCVwaslaunchedinMay2017forreducinginfant
mortalityandmorbiditycausedbypneumococcalpneumonia.
he
vaccinehasbeenintroducedinHimachalPradesh,
6districtsofUttarPradeshand17districtsofBihar
MadhyaPradesh,andHaryana.TillSeptember2019,around
192.49lakhchildrenwerevaccinated(11).
RODUCTIONOFROTAVIRUSVACCINE
Rota
virusvaccinewasintroducedin2016inOdisha,
achalPradesh,HaryanaandAndhraPradesh,andlater
willbeexpandedtothewholecountry.Itwillbegiven
leruniversalimmunizationprogrammeasa3dose
cinealongwithpentavalent1st,2ndand3rddose(6).
Veryfrequentlyqueriescomeupaboutthevaccinesand
thevaccinationschedule.Itisimportanttohavetheexact
answertothesequestions.
"BELLA
VACCINE
To
beinitiatedasMeaslesRubella(MR)campaign
geting9monthsto15yearsofageinaphasedmanner
eraperiodofthreeyears.Subsequently,theRubella
cinewillbeintroducedasMRvaccineastwodosesinthe
iceotmeaslescontainingvaccine
1and2at9-12months
dlb-24monthsasperNTAGIrecommendations(6)
Questionsaboutallvaccines(43)
Q.Ifthemother/caregiverpermitsadministrationofonly
oneinjectionduringanintant'sfirstvisitat9monthsof
age,whichvaccineshouldbegiven?
A.At9monthsofage,thepriorityistogivemeasles
vaccinewithOPVandVitamin-A.
Q.Whichvaccinescanbegiventoachildbetween
1-5yearsofage,whohasneverbeenvaccinated?
ISSIONINDRADHANUSH
IheMinistryofHealth
&&
FamilyWelfarehaslaunched
0nIndradhanush",depictingsevencoloursoftne
O,inDecember2014,tofullyimmunize9upercent
arenwhoareeitherunvaccinatedorpartialy
eathosethathavenotbeencoveredduringthe
020
TTOutineimmunizationforvariousreasons,by
.Ihe
target
hasnowbeenpre-ponedtoZ018(/).
tonIndradhanush
hascompletedsixpnases
20pril2015toDec.2018)covering681districtswnerein
meChildrenwerereached;81.79lakhchildrenwere
A.ThechildshouldbegivenDPT1,OPV-1,measlesand
2mlofvitaminAsolution.Itshouldthenbegiventhe
secondandthirddosesofDPTandOPVatonemonth
intervals.Measlesseconddoseisalsotobegivenasperthe
schedule.TheboosterdoseofOPV/DPTcanbegivenata
minimumof6monthsafteradministeringOPV3/DPT3.
Q.Whichvaccinescan
begiventoachildbetween
5-7yearsotage,whohasneverbeenvaccinated?
A.Thechildshouldbegivenfirst,secondandthirddoses
ofF
DPTatonemonthintervals.TheboosterdoseofDPT
canbegivenat
a
minimumot6monthsafter
administeringDPT3upto7yearsofage.
Q.Shouldonere-startwiththefirstdoseofavaccineif
a
childisbroughtlateforadose?
A.Donotstarttheschedulealloveragainevenifthechil
isbroughtlateforadose.Pickupwheretheschedul
wasleftoft.Forexample:ifachildwhohasreceive
BCG,HepB-1,DPT-1andOPV-1at5monthsofage
returnsat11monthsofage,vaccinatethechildwit
DPT-2,HepB-2,OPV-2andmeaslesanddonotsta
fromDPT-1,HepB-lagain.
nunized;
and87.18lakhpregnantwomenwere
nmunized.
ThefirsttwophasesofMissionIndradhanushave
led
toveraaean
increaseof6.7percentinfullimmunization
e
year,ascomparedto1percentinthepast.
increase
wasmore
inrur
compar
as
moreinruralareas(7.9percent)as
usofth
rban
areas(3.1percent),henceshiftingthe
programme
towardsurbanareas(l.
nsified
Mission
Indradhan Atotalof190districts/
ihedmissi
indradhanushhasstarted.Itwaslaunched
nlensifiod,across24stateshavebeenidentifiedwhere

110. 511
vision
forsafeabortionservicesandbloodPRADHANMANTRIsURAKSHITMAIKITV
rai
ansfusion.Terminanon
orpregnancywithRU486
ABHIYAN(PMSMA)
ThePradhanMantriSurakshitMatritva
Abhiyan(PMSMA)
nasbeenlaunchedbytheMinistryinJune,2016.Under
MSMA,
allpregnantwomeninthecountryareprovided
TIxedday,freeofcostassuredandqualityantenatal
care.Hs
partofthecampaign,aminimumpackageofantenatal
care
ncluding
investigationsanddrugs)isbeing
providedtothebeneficiariesonthe9thdayofeverymontn.
heAbhiyanalsoinvolvesprivatesector
shealtn
care
providerSasvolunteerstoprovidespeCialist
caren
governmentfacilities.About2.20croreANCcheck-ups
were
conductedbyabout6,000volunteersinmorethan17,000
governmenttacilities.Also,morethan11.66lakhhighrisk
pregnancycaseswereidentifiedacrossthecountry(11).
Misoprostolisofteredtowomenunderthe
areviewoftheMTPAct,1971.
fanualVacuumAspiration(MVA):
Thedepartment.
familywelfare
nasintroducedManualVacuum
Aspiration(MVA)techniqueinthelamilywelfare
ano
nrogramme.ManualvacuumAspirationisasafeand
simple
techniqueforterminationofearlypregnancy,
makes
it1easibieoe
usea1nprimaryhealthcentres
orComparablefacilities.therebyincreasingaccessto
safeabortionservices.1heproject
ofintroducingthe
MVAtechniquehasbeenpilotedincoordinationwith
FOGSI,WHOandrespectivestategovernments
beforebeingacceptedtorimplementationbythe
ministryofhealthandfamilywelfare.
SUMAN(SurakshitMatritvaAashwasan)
VillageHealthandNutritionDay
OrganizingVillageHealthandNutritionDayoncea
monthatanganwadcentretoprovideantenatal/post-
partumcare1orpregnantwomen,promoteinstitutional
delivery,healtheducation,immunization,tamilyplanning
Ministryhaslaunchedanewinitiativenamely"SUMAN
SurakshitMatritvaAashwasan"on10thOctober,2019withan
aim
toprovideassured,dignified,respectfulandquality
healthcareatnocostandzerotolerancetordenialofservices
oreverywomanandnewbornvisitingthepublichealthtacility
inordertoend
allpreventablematernalandnewborndeaths
andmorbiditiesandprovideapositivebirthingexperience.
andnutritionservicesetc.
Maternaldeathreview
Maternaldeathreview
asastrategyhasbeenspeltout
clearlyintheRCH-11.Maternaldeathaudit,bothfacilityand
communitybased,
isanimportantstrategytoimprovethe
qualityofobstetriccareandreducematernalmortalityandLAQSHYAPROGRAMME (11)
morbidity.Guidelinesandtoolstorinitiatingmaternaldeathn
reviewhavebeenformulated(3).
Theexpectedoutcomeofthisnewinitiativeis"Zero
preventablematernalandnewborndeathsandhighquality
ofmaternitycaredeliveredwithdignityandrespect(11).
MOHFW launched"LaQshyaprogram
toimprove
qualityofcareinlabourroomandmaternityOlsinpublic
healthfacilitiesin2017.TheLaQshyaprogrammeis
evidencebasedapproachtoimprvequalityofmaternal
andnewborncareandproviderespecttulcare.particularly
duringtheintrapartumandpostpartumperiods,whichare
themostvulnerableperiodsforawomanandcontributetoa
significantproportionofmaternaldeaths.
Pregnancytracking
Thelinkbetweenpregnancy-relatedcareandmaternal
mortalityiswellestablished.RCH-IIstressestheneedfor
universalSCreeningofpregnantwomenand
providingg
essentialandemergencyobstetriccare.Focussedantenatal
care,birthpreparednessandcomplicationreadiness,skilled
arendanceatbirth,carewithinthefirstsevendaysetc.are
thefactorsthatcanreducethematernalmortality(3).
Itsimplementationinvolvesimprovinginfrastructure
upgradation,ensuringavailabilityofessentialequipment
providingadequatehumanresources,capacitybuildingof
healthcareworkers,andadherencetoclinicalguidelinesand
improvingqualityprocessesinlabourroomandmaternityOT.
LaQshyaprogramisbeingimplementedatDistrictHospital
(DH),SubdistrictHospital(SDH),highcaseloadCommunity
HealthCentre(CHC)andFirstReferralUnits(FRUS),and
medicalcolleges.2,445publichealthfacilitiesincluding
193medicalcollegeshavebeenidentifiedunderLaQshya.Out
ofthese,441labourroomsand39201shaveachievedstate
certification.Natio
achievedby152labourroomsand127OTstillOctober,2019.
JANANI-SHISHUSURAKSHAKARYAKRAM (JSSK)
GovernmentofIndialaunchedtheJanani-Shishu
SurakshaKaryakram(JSSK)on1stJune2011,a
new
nationalinitiative,tomakeavailablebetterhealthfacitlies
OTwomenandchild.Thenewinitiativesprovidethe
O1OWingfacilitiestothepregnantwomen(54/.
Alpregnantwomendeliveringinpublichealth
institutionstohaveabsolutelyfreeandnoexpense
aelivery,includingcaesareansection.Theentitlemenis
ude
freedrugsandconsumables,freedietupto3days
auringnormaldeliveryandupto7daysforC-section,
aiagnostics,andfreebloodwhereverrequired.I
his
ative
wouldalsoprovideforfreetransportiromhome
toinstitution,betweenfacilitiesincaseofareterralana
ropbackhome.Similarentitlementshavebeenputin
Placeforalsicknewbornsaccessingpublichealth
Institu
fortreatmenttill30daysafterbirth.he
has
nowbeenextendedto
coverthe
mplicationsduringANC,PNCandalsosickintants
neschemeisestimatedtobenefitmorethan
for
womenwhoaccessgovernmenthealthtacilities
sHtheirdelivery.Moreover,itwillmotivatethose
wno
insfitsetodeliverattheirhomestooptfor
icationtorLashya hasbeen
Regionaltrainingsoftrainershavebeencompletedforall
States/UTsacrosscountrytobuildacriticalmassoftrainers
whotookthistrainingcascadefurther.Stateorientationand
baselineassessmenthavebeenconductedforallState/UTs.
Basedonthegaps,tnestateshavepreparedgapclosure
plan.Onsitementoringisbeingconductedin24identified
medicalcollegestoaccelerateprocessofcertificationin
medicalcolleges.Layshyaportalhasbeenfinalizedand
operationalized.DatauploadonLaQshyaportalhasbeen
initiatedtoaiddigitizationotallLaQshyarelateddata,
readilyavailableresultsandvisualizationthroughdashboard.
2million
ANAEMIAMUKTBHARATPROGRAMME
Toaddresstheproblemofmalnutritionthefocusof
PoshanAbhiyaanonthefirst1000daysofthechild,which
institutional
deliveries.

111. 512
HEALTHPROGRAMMES ININDIA
includestheninemonthsofpregnancy,sixmonthsof
exclusivebreast-feedingandtheperiodfrom6monthsto
2yearstoensurefocussedinterventionsonaddressing
under-nutrition.Besidesincreasingthebirthweight,itwill
helptoreducebothInfantMortalityRate(MR)andMaternal
MortalityRate(MMR).Additionaloneyearofsustained
intervention(tilltheageof
3years)wouldensurethatthe
gainsofthefirst1.000daysareconsolidated.Attentionis
alsogivenonchildrenintheagegroupof3-6yearsfortheir
veralldevelopmentthroughtheplatformoftheAnganwadi
Centres(AWCs).OnesuchinitiativeunderthePoshan
Abhiyaanistopromotebehaviourchangeamongthe
communitiesandtoimprovematernalandchildnutritionby
organizingcommunity-basedeventsinastructuredway(54)
Managementofmedicalcomplicatio
inachildwithSAMathealthfacility(55
Amajorityofthedeathsinhospitalsoccurwithi
hoursofadmission,manyofthesedeaths
can
hon
ifthecriticallyillchildrenareidentifiedassoon
theyadmittedandtheirtreatmentisstartedimmediatelu
Triage
Triageistheprocessofrapidlyscreeningsickchild-
Triagemustbedoneforallpaediatricpatientscomingto
healthfacility.Thefirststepistocheckevery
childemergencysignsandprovideemergency
treatment
necessary,keepingin
mindtheABCDstepsAiru
Breathing,Circulation,Coma,ConvulsionandDehydrati
Childhealthcomponents
Thestrategyforchildhealthcare,aimstoreduceunder-
fivechildmortalitythroughinterventionsateverylevelof
servicedeliveryandthroughimprovedchildcarepractices
andchildnutrition.
Assessmentatadmission(55)
Thechildshouldbeassessedbytakingdetailedhist
andshouldbeexaminedforthesignsofunder-nutrition
Principlesofhospital-basedmanagement
(55)
TheprinciplesofmanagementofSAMarebased
on
phases:stabilization
rehabilitativephase.
Nutritionalrehabilitationcentres(NRCs)
Severeacutemalnutritionisanimportantcontributing
factorformostdeathsamongchildrensufferingfrom
commonchildhoodillnesssuchasdiarrhoeaandpneumonia.
Deathsamongthesemalnourishedchildrenarepreventable,
orovidedtimelyandappropriateactionsaretaken.NRCsare
acilitybasedunitsprovidingmedicalandnutritionalcareto
evereAcuteMalnutrition(SAM)childrenunder5yearsof
gewhohavemedicalcomplications.Inadditionspecial
cusisonimprovingtheskillofmothersonchildcareand
edingpracticessothatthechildcontinuestogetadequate
are
athome.TheservicesprovidedattheNRCsinclude(1):
24hourscareandmonitoringofthechild
Treatmentofmedicalcomplication;
Therapeuticfeeding;
Sensorystimulationandemotionalcare;
Counsellingonappropriatefeed,careandhygiene;
Demonstrationandpractice-by-doingonthepreparation
ofenergydensefoodusinglocallyavailable,culturally
acceptableandaffordablefooditems;
Socialassessmentofthefamilytoidentifyandaddress
contributoryfactors;and
Followupofthechildrendischargedfromthefacility.
phase,transitionphasea
StabilizationPhase:ChildrenwithSAMwithoutanadequae
appetiteand/oramajormedicalcomplicationarestabilized
anin-patientfacility.Thisphaseusuallylastsfor1-2
dau
ThefeedingformulausedduringthisphaseisStarterdietwhi-
promotesrecoveryofnormalmetabolicfunctionandnutiic
-electrolyticbalance.Allchildrenmustbecarefullymonitor=
forsignsofoverfeedingoroverhydrationinthisphase.
TransitionPhase:Thisphaseisthesubsequentpartoft
stabilizationphaseandusuallylastsfor2-3days.
TH
transitionphaseisintendedtoensurethatthechild
clinicallystableandcantolerateanincreased
energy
ar
proteinintake.ThechildmovestotheTransitionPhasefro
StabilizationPhasewhenthereis:
Atleastthebeginningoflossofoedema.
AND
Returnofappetite.
AND
Nonasogastrictube,infusions,noseveremedicalproblem
AND
Isalertandactive?
Takeahistoryconcerning
ecentintakeoffoodandfluids
sualdiet(beforethecurrent Oedema.
illness)
Onexamination,lookfor
Anthropometry-weight,height/length,midarmcircumference.
reastfeeding
urationandfrequencyof
diarrhoeaandvomiting
pe
ofdiarrhoea(watery/
bloody)
roniccough
s
ofappetite
nilycircumstances(to
nderstandthechild'ssocial
Pulse,heartrate,respiratoryrate.
Signsofdehydration.
Shock(coldhands,slowcapillaryrefill,weakandrapidpulse).
Palmarpallor.
EyesignsofvitaminAdeficiency:
-Dryconjunctivaorcornea,
-Bitot'sspots
Cornealulceration
Keratomalacia
oniai
ackground).
tactwithtuberculosis
Localizingsignsofinfection,includingearandthroatinfections,skininfectionorpneum0
Mouthulcers.
entcontactwithmeasiles
Skinchangesofkwashiorkor:
wnorsuspectedHIV
ection
unizations
Hypoorhyperpigmentation
Desquamation
Ulcerationspreading
overlimbs,thighs,genitalia,groin,and
behindthe
ears
ndidal
Exudativelesions(resembling
severe
burns)oftenwithsecondaryinfection(includn

112. 534
AYUSHMAN
BHARATPROGRAMM
HEALTH
PROGRAMMES ININDIA
InFebruary
2018,the
Govt.ofIndia
nound
major
initiativesin
healtnsectorwithaimttwo
preventiveand
nealtn
promotive
interventions
Cove
secondaryand
tertiary
caresystem.Theyareasfolllmary
1.Healthand
WellnessCenter:TheNationalHeal
2017has
envisionedHealthand
WellnessCentoolicy
foundationofIndia
shealth
system.Underthis
1the
centers
willbringhealth
Caresystemcloserto
F
people.Thehealth
centerswillprovide
comDro
of
healthcare,includingmaternalandchildhealthcSive
CommunicableDiseases
services,anaservicesrelated
Non-CommunicableDiseases.obeginwith
commonNCDSSuchasnypertension,diabetesand
commoncancersoforal,breastandcervix.
Jtis
envisaged
toincrementallyadd
primaryhealthe
Unusualisolate
Shiftinginage
distributionof
cases
Sudden
increase/highvector
density
Naturaldisasters
stem.
Theyareastollows(69
Summaryof
outbreak
syndromesandtrigger
eventsTor
investigation(6/)
h
Syndrome
Irigger
event
Asingle
caseot
severe
dehydration/deathinapatient
5yearsofagewithdiarrhoea.
Acutewatery
stools
Morethan10houseshavingat
eastonecaseofloosestools
irrespectiveofage,pervillageor
anurbanward.
servicesformentalhealth,
ENT,opthalmolo
ogy,
are
health,geriatricandpalliativehealthcareand
traums
care,aswellashealthpromotionandwellness
activitioe
likeYoga.AtewStates/uIshavealreadystartedrolin
outtheseadditionalpackagesofservicesina
phasod
manner.Thecenterswillalsoprovidefreeessentialdruos
anddiagnosticservices.
Fever<7days
duration
5casesin1000population.
(a)Onlyfever
(b)Withrash
(Measles
Dengue)
Twosimilarcasesinavillage
(1000population).
2.Thesecondcomponent1s
theAyushmanBharat
PradhanMantriJanArogyaYojana(AB-PMJAY)which
provideshealthcoverageuptoRs.5.00lakhperfamily
per
yeartoabout10.74crorepoorandvulnerable
familiesidentifiedonthebasisofSocioEconomicCaste
(c)Altered Iwocasesoffeverwithaltered
consciousness
inthevillage/1O00
population.
consciousness
(d)Feverwith
bleeding
Twocasesoffeverwithbleedingina
villageor1000population.
Censusdata.
Feverwith Twocasesoffeverwithconvulsions
inavillageor1000population.
ThefirstHealthandWellnessCentrewasinauguratedon
14thApril2018inBijapurdistrictofChhattisgarh.Sofar,
22,559centresareoperationalinthe
countryason22nd
October2019,whichincludes8,075SHC-HWCs,11,716
PHC-HWCsand2,769UPHC-HWCs(11).
PrimaryhealthcareteamattheSubHealthCentrelevel
AB-HWCsisheadedbyCommunityHealthOfficer(CHO)
whoisa
BSc/GNMNurseoranAyurvedaPractitioner
trainedinprimarycareandpublichealthskills,andcertified
in
asixmonthscertificateprogrammeincommunityhealth.
Othermembersoftheteambeingmulti-purposeworkers
(MaleandFemale)andAccreditedSocialHealth
ActivVIsts
(ASHAs)
convulsions
Morethan2casesinavillageor1000
population.
Fevermore
than7days
Morethan2casesinavillageorin
1000population.
Morethan2deathsor
Jaundice
Unusualevent
hospitalization.
Thereportingunitsfordiseasesurveillanceare
PublicHealthSector PrivateHealthSector
RuralCHCs,District
hospitals
Sentinelprivate
practitioners,and
Sentinelhospitals.
Sentinelprivate
nursinghomes,
Medicalcollegehospitals.sentinelhospitals,
Medicalcolleges,
Privateand
Thetrainingprogrammeisbeingcarriedoutwithsupport
fromIGNOUandstatespecificPublic/HealthUniversities.
282IGNOUProgrammeStudyCentres(PSCs)havebee
notifiedsofar,andanother111PSCshavebeennotiie
underthestatespecificcertificateprogramme
inthestateo
Maharashtra,TamilNadu,GujaratandWestBengal,tak
tnetotalofprogrammestudycentresto393
across
country.
UrbanOrbanhospitals,
ESI/Railway/
NGOlaboratories
1.Sub-centre-healthworker/ANM
reportsallpatients
fulfillingtheclinicalsyndromefromPHC,private
clinic,hospitaletc.
2.PHC/CHC
medicalofficersreportasprobablecasesofinterest,wherethiscannot
becontirmedbylaboratorytestsattheperipheralreportingunits,andasconfirmed
whenthelaboratory
intormation
isavailableasincaseofbloodsmear+ve
malariaand
Sincethescreening,preventionandmanagemen
chronicillnessesincludingNCDs,TBandLeprosy
beenintroducedatAB-HWCs,
trainingandskillupgradau
OtheprimaryhealthteaminallthefunctionalAB-HW
NCDsanduseofITapplication
isbeing
done.
sputumAFB+vetuberculosis.
3.Sentinel
privatepractitioners,
district
hospitals,municipal
hospitals,
medical
colleges,
sentinel
hospitals,
NGOs -
medical
officersreportasprobable
lopromotewellness
andhealthylifestyle,orientatio
thepubliconwellness
activitiesforlifestyle
modiican=increasedphysical
activity(cyclathons
andmaraeatingRIGHT
andSAFE,
cessationoftobaccoa
dru
meditation,
laughter
clubs,opengyms,e
datthe
Besidethese,Yoga
sessionsarebeingconductecentresonregularbasis.Throughannualhealt
casesofinterest.
calend

113. ct.
itiesatthesecenesonthehealthcondilion
AYUSHM:BARAT
PREHGRAMM 53
inincreasedawareness
andpreventive
theday
are
resultingin
day1o
beadoptedbythepublic.
ernational
CommissionforCertificationofDracunculiasis
Eradication,Geneva
:
planned
icineguidelineshavealsobeenprovidedto
The
tele
initiatespeclalisconsuliationsfromthe
Sta HubHospilalsananepioto1theapplication
is
Pradesh,TamilNaduand
.Health
educationactivitieswithspecialemphasison
Schoolchildrenandwoneninruralareas;
.
Rumourregistrationandrumourinvestigation
C.Maintenanceofguinea-wormdiseaseonlistot
nofifiablediseaseandcontinuationiofsurvellance
n
previouslyinfectedareas,and
Carefulsupervisionofthefunctioningofhandpumps
andothersourcesofsafedrinking
water,and
provisionofadditionalunits,wherever
necessary.
PHCstothe
nductednAndhra
aharasntra.
Mah
edservicepackagesplannedtobeprovided
being
functional
AB-HWCsareas1ollows
Care
in
pregnancyandchildbirth.
anatalandintanthealthcareservices.
2hoodandadolescenthealthcareservices.
YAWSERADICATIONPROGRAMME (9)
Familyplanning.contraceptiveservicesandother nediseasehasbeenreportedinIndiafromthetriba
unities
livinginhillyforestanddifficulttoreachareas
ctivehealthcareservices.
anagementofcommunicablediseases
Nationalin49districtsof10states,
namelyAndhraPradesh.
Health
programmes.
Ceneralout-patientcare1oracutesimpleillnessesand
nattisgarh,Gujarat,Jharkhand.
MadhyaPradesn,
ianarashfra,Orissa,TamilNaduandUttarPradesn.
aOna
InstituteofCommunicableDiseasesisthenodal
agencyorplanning,guidance,coordination,moiitorng
andevaluationoftheprogramme.Theprogranne
mpiementedbytheStateHealthDirectorates
otYaws
endemicstatesutilizingexistinghealthcaredeliverysystem
WIhthecoordinationandcollaborationotdepartmentot
tribalweltareandotherrelatedinstitutions.
6.
minor
ailments.
Screening.prevention,controlandmanagemen
communicablealseasesandchroniccommunicable
diseaseslike
tuberculosisande
onic
common
S.Basicoralhealth
care.
oScreeningandbasicmanagementofmentalhealth
ailments.
10.CareforcommonophthalmicandENTproblem.
11.Elderlyandpalliativehealthcareservices.
12.Emergencymedicalservicesincludingburnsandtrauma.
Thenumberofreportedcaseshascomedownfrommore
than3,500toNilduringtheperiodfrom1995to2004.
sincethennonewcasehasbeenreported.
NATIONALPROGRAMME FORCONTROLAND
TREATMENT OFOCCUPATIONAL DISEASESS
Expectedoutcome(11)
Increasingthetrustofpeopleontheserviceprovisionby
publichealthcarefacilitiesthroughhealthsystem
strengtheningandimprovement.
Availabilityofassuredhealthcareservicestoensure
Government
ofIndialaunchedaschemecalled"National
ProgrammeforControlandTreatmentofOccupational
Diseases"in1998-99.TheNationalInstituteoft
OccupationalHealth,Ahmedabad(ICMR)hasbeen
identifiedasthenodalagencytorthisprogramme.
continuumotcare.
Reductioninoutofpocketexpenditureofthecommon
people.
Increased
awarenessamongthepeopleaboutpreventive
andpromotivehealthcare.
BenefitsofhealthylifestyleincludingYoga,andeatright
Thefollowingresearchprojectshavebeenproposedby
the
government(70):
1.Prevention,controlandtreatmentofsilicosisand
silico-tuberculosisinagateindustry:
2.Occupationalhealthproblemsoftobaccoharvesters
andtheirprevention;
&eatsafeetc.
Enablingenvironmenttoincreasethehealthseeking
behaviourofthepoorpeople.
3.Hazardousprocess
generation,documentation,
andchemicals,database
andinformation
dissemination;
NATIONALGUINEAwORM
ERADICATIONPROGRAMME
4.Capacitybuildingtopromoteresearch,education,
andtrainingatNationalInstituteofOccupational
Disease;
IndialauncheditsNationalGuineawormEradication
rogramme
in1984withtechnicalassistancefromWHO.
romtheverybeginningtheprogrammewasintegratedinto
ne
nationalhealthsystem
atvillagelevel.Withwelldefined
egies,anefficientinformationandevaluation
sysrem,
ersectoralcoordinationatalllevelsandclosecollaboration
WHOandUNICEF,Indiawasabletosignificantlyreduce
aisease
inaffectedareas.Thecountryhasreportedzero
s
sinceAugust1996.InFebruary2000,theInternational
missionfortheCertificationofDracuncullasi
cationrecommendedthatIndiabecertifiedtreeor
oracunculiasis
transmission
(00/
5.HealthRiskAssessmentanddevelopmentof
interventionprogrammeincottageindustrieswith
highriskofsilicosis;and
6.Preventionandcontrolofoccupationalhealthhazards
amongsaltworkersintheremotedesertareasof
GujaratandWesternRajasthan.
NUTRITIONALPROGRAMME
Pleaserefertochapter12,fordetails.
NATIONALFAMILYWELFAREPROGRAMME
1llowingactivitiesarecontinuingasper
atons ofInternationalCertificationTeamof Seechapter10fordetails.

114. 8
EssentialMedicines
andCounterfeitMedicines
Counterfeitmedicinesareacrimeagainsthumanity
ceptofessentialmedicines(1)
7.Priceofthetotaltreatmenttobeconsideredandnotthe
unitpriceofamedicine;
almedicinesarethosethatsatisfythepriority
reneedsofthepopulation.ESsentialmedicinesare
tobeavailablewithinthecontextoffunctioning
Jstemsatalltimesinadequateamounts,inthe
atedosageforms,withassuredqualityand
information,andatapricetheindividualandthe
itycanafford.Theimplementationoftheconcept
ntialmedicinesisintendedtobe
flexibleand
letomanydiflerent
situations;exactlywhich
esareregardedasessentialremains
anational
ibility.Experiencehasshownthatcarefulselectionof
drangeofessentialmedicinesresultsinahigher
ofcare,better
managementofmedicines
(including
2dquality
ofprescribed
medicines),andamorecost
euseofavailablehealthresources.
8.Fixeddosecombinationaregenerallynotincluded
unlessthecombinationhasunequivocally
proven
advantageoverindividualingredients
administered
separatelyintermsofincreasingetficacy,reducingside
effectsand/orimprovingcompliance;
9.Thelistofessentialmedicinesisbasedaccordingtothe
levelofhealthcarei.e.Primary(P),Secondary
(S)and
tertiary(T)becausethe
treatmentfacility,training,
experienceandavailabilityofhealth
carepersonnel
differattheselevels.
Dosage
forms/formulationsofamedicine
nallistofessential
medicinesof
-2015
(2)
firstNationalListof
EssentialMedicinesinIndiawas
edintheyear1996,thislistwassubsequentlyrevised
year2003,2011and2015.
medicineshavebeen
categorizedaccordingto
euticuse,hence,itispossiblethat
amedicinewith
thanoneindication
appearsin
morethanone
Formulationofamedicinemaybe
availablein
different
dosageforms.Oralsoliddosageform
includes
tablet,
capsule,,sachet
etc.Tablets
include
immediate-release
tabletslikefilmcoated,uncoated,
sugarcoated,
crushable,
chewableand
dispersibleetc.Entericcoated
ontheother
hand,
modifiesdrugrelease.
Crushable,
chewableand
dispersibletablets
maybeeasierto
administer
topaediatric
andelderly
cases.Capsules
includehardgelatin
capsue,
Soitgelatin
capsule
etc.(unless
specitied,
capsules
mentionedinthelistare
consideredashard,
gelatin
capsules).
Oralliquiddosage
formsinclude
syrup,suspension,
elixirsetc.
Injectabledosageforms
includecon
oru
quia
in)Jectionorpowderfor
injection,aswellas
aenv
systemIke
depot,
liposomal/lipid
complexetc0pca
dosage
tormsinclude
ointment,
cream,lotion,
dropsetc
ory.
diahasadoptedthe
conceptofEssentialMedicinesas
Duncedbythe
WHO.
However,India'slistof
essential
cinesisdifferentfromthelistissuedbyWHOdueto
encesinnational
circumstances.
Thelistofessential
cines
containssuch
medicines
thatsatistythe
priority
hneeds
ofthe
country's
population,
addressing
itsown
seburden.
The
medicinesused
invarious
national
th
programmes,emergingand
re-emerging
infections
ncluded
inthislist
ofessential
medicines.The
criteria
for
inclusion
of
amedicine
innationallistisas
Monitoringof
medicinesafetyand
pharmacovigilance
atety
monitoringisan
important
partoftheo
surveillanceofmedicineuse.Theaimsofthe
varnouu
of
pharmacovigilance
areto
identify
new,
prevo
unrecognized
adverse
effectsof
medicines,toquant
risks,andto
communicatethese
touant
the
authorities,health
professionals,
ana,wedicines,
puoic.
voluntary
reportingofadverse
etfectsOnld
onwhichthe
International
WHO
Programmea
Monitoring
isbased,has
been
effectiveinident
of
number
of
previously
undescribed
effects.
The
ma cing
the
riskofadverse
effects
isgeneraly
evaacase
bservational
epidemiological
methods,such
control,
cohortand
case-population
studies.
The
Governmentof
India
approvedlisto
etical
meaicinesisas
tollows.
Medicinesare
listedin
aip
order
withinsections(2).
latory
ws(
The
medicineshouldbe
approved/licensedinIndia;
The
medicine
shouldbe
usetulindisease
whichisa
public
health
probleminIndia;
It
shouldhave
proven
etficacyand
saiety
profile
based
onvalid
scientific
evidence;
Itshouldbe
cost
effective;
essential
Itshouldbe
aligned
withthe
current
treatment
guidelines
forthe
disease;
Itshouldbe
stable
underthe
storage
conditionsin
India;

115. 541
NATIONALLISTOF
ESSENTIALL
MEDICINEES
Nationallistofessentialmedicines2015
Dosageformandstrength
LevelofDosageformandstrength
Healthcare
Medicines Medicines Levelol
Healthcare
Section1:Anestheticagents
1.1GeneralAnestheticsandoxygen
2.2:Oploidanalgesics
S,T Injection50
meg/ml
Tablet10mg
Injection10mg/ml
Injection15mg/ml
Capsule50mg
Capsule100mg
Injection50mg/ml
2.2.1Fentanyl
Halothane S,T Inhalation 2.2.2Morphine PS,T
1.1.1
S,T Inhalation
1.1.2Isofturane
Ketamine
1.1.3
PS,T Injection10mg/ml
Injection50mg/ml
TramadolS,T2.2.3
Nitrousoxide PS,T Inhalation
1.14
PS,T Inhalation(Medicinalgas)
2.3Medicinesusedtotreatgout
Tablet100mg
Tablet300mg
1.1.5Oxygen
PS,T Injection10mg/ml
1,1.6
Propofol
1.1.7Sevoflurane
1.1.8Thiopentone
2.3.1Allopurinol PS,T
T Inhalation
PowderforInjection0.5g
PowderforInjectionlg
PS,T
2.3.2Colchicine PS,T Tablet0.5mg
2.4:Diseasemodifyingagents
usedinrheumatoiddisorders1.2:Localanesthetics
Injection0.25%
Injection0.5%
Injection0.5%with
7.5%glucose
Topicalforms2-5%
Injection1%
Injection2%
Injection5%with
7.5%Glucose
S,T Tablet50mgAzathioprine S,T
Hydroxy-
chloroquine
1.2.1
Bupivacaine
2.4.1
Tablet200mg
Tablet400mg
2.4.2 S,T
Tablet10mg
Tablet20mg
2.4.3Leflunomide S,T
1.2.2Lignocaine P.S,T
Tablet5mg
Tablet7.5mg
Tablet10mg
Injection25mg/ml
Tablet500mg
2.4.4MethotrexateS,T
Injection1%(A)+
1:200000(5mcg/ml)(B)
Injection2%(A)+
1:200000(5mcg/ml)(B)
Lignocaine(A)+PS,T
Adrenaline(B)
1.2.3
2.4.5SulfasalazineS,T
Section3:Antiallergicsandmedicinesusedinanaphylaxis
Injection
1mg/mlPS,T
PS,T
3.1 Adrenaline
Prilocaine(A) T
Lignocaine(B)
Cream2.5%
(A)+
2.5%(B)
1.2.4
Tablet10mg
Oralliquid5mg/5ml
3.2 Cetirizine
1.3Preoperativemedicationandsedationfor
shorttermprocedures
Tablet4mng
Oralliquid2mg/5ml
3.3 ChlorpheniraminePS,T
1.3.1 Injection0.6mg/ml
Injection0.2mg/ml
Atropine RS,T
Tablet0.5mg
Injection4mg/ml
PowderforInjection100mg
3.4DexamethasonePS,T
1.3.2GlycopyrrolateS,T
13.3Midazolam PS,T Tablet7.5
mg
3.5 HydrocortisonePS,T
Tablet15mg
Oralliquid2mg/mli3
Injection
1mg/mi
Injection5mg/ml
3.6 PS,TPheniramine
PrednisolonesRS,T
Injection22.75mg/ml
Tablet5mg
Tablet10mg
Tablet20mg
Oralliquid5mg/5ml
Oralliquid15mg/5ml
3.7
1.3.4Morphine PS,T Injection10mg/ml
Injection15mg/ml
Section2:Analgesics,antipyretics,nonsteroidalanti-
Section4:Antidotesandother
substancesusedinpoisoning
4.1Nonspecific
ntlammatorymedicines,medicinesusedtotreatgoutand
diseasemodifyingagentsusedinrheumatoiddisorders
2.1Non-opioidanalgesics,antipyreticsand
nonsteroidalanti-inflammatorymedicines
Tablet300mgto500mg
Effervescent/Dispersible/
4.1.1ActivatedcharcoalPS,T Powder(aslicensed)
2.1.1Acetylsalicylic
PS,T
acid
4.2:Specific
4.2.1Atropine
4.2.2Calcium
PS,T Injection1mg/ml
Injection100mg/ml
Entericcoated
PS,T
Tablet300mgto500mg
Tablet50mg
Injection25mg/ml
Tablet200mg
Tablet400mg
Oralliquid100mg/5ml
Capsule250
mg
Capsule500
mg
Oralliquid100mg/5ml
Tablet500mg
Tablet650mg
Alllicencedoralliquid
dosageformsandstrengths
Injection150mg/ml
Suppository80mg
Suppository170
mgg
2.1.2
Diclofenac
P.S,T
gluconate
4.2.3DesferrioxamineS,T
Powderfor
2.1.3 njection500mg
Injection50mg/ml
Injection10mg/ml
tbuprofen PS,T
Dimercaprol
Methylthioni-
niumchloride
Methyleneblue)
4.2.4 S,T
4.2.5 S,T
2.14
Mefenamic
acid
RS,T
4.2.6N-acetylcysteinePs,T Sachet200mg
Injection200mg/ml
Injection0.4mg/ml
Injection0.5mg/ml
Capsule250mg
2.15
ParacetamolPS,T
4.2.7Naloxone PS,T
4.2.8Neostigmine PS,T
4.2.9PenicillamineS,T
PS,T4.2.10Pralidoxime
Injection25mg/mi
chloride(2-PAM)

116. 542
ESSENTIALMEDICINESANDCOUNTERFEITMEDICINES
LevelofDosageformandstrength
Healthcare
Medicines LevelofDosageformandstrength Medicines
Healthcare
4.2.11Snakevenom PS,T 6.2:Antibacterials
antiserum
6.2.1:Betalactammedicines
a)Soluble/liquid
polyvalent
b)Lyophilized
polyvalent
a)Injection
Capsule250mg
Capsule500mg
Oralliquid250mg/5ml
Tablet500mg(A)+
125mg(B)
Oralliquid200mg
(A)+
28.5mg(B)/5ml
DrySyrup
125
mg(A)+
31.25(B)/5ml
PowderforInjection
500mg(A)+100
mg(B)
PowderforInjection
1g(A)+200
mg(B)
PS,Ts PowderforInjection500mg
PowderforInjection1g
PowderforInjection
6lacunits
PowderforInjection
12lacunitsar
PowderforInjection
10lacunits
6.2.1.1Amoxicillin PS,T
b)PowderforInjection
6.2.1.2Amoxicillin(A)+PS,T
Clavulanicacid(B)
4.2.12SodiumnitriteS,T Injection30mg/ml
4.2.13Sodium S,T Injection100mg/mi
thiosulphate
Section5:Anticonvulsants/Antiepileptics
5.1 Carbamzepine Tablet100mg
Tablet200mg
CRTablet200mg
Tablet400mg
CRTablet400mg
Oralliquid100mg/5ml
Oralliquid200mg/5ml
PS,T
S,T
6.2.1.3Ampicillin
5.2 Clobazam S,T Tablet5mg
Tablet10mg
6.2.1.4Benzathine PS,T
benzylpenicillin
5.3 Diazepam PS,T Oralliquid2mg/5ml
Injection5mg/ml
Suppository5mg
6.2.1.5BenzylpenicillinPS,T
5.4 Levetiracetam Tablet250mg
Tablet500mg
Tablet750mg
ERTablet750mg
Oralliquid100mg/ml
Injection100mg/ml
S,T
Tablet500mg
Tablet1g
6.2.1.6Cefadroxil RS,T
Oralliquid125mg/5ml
PowderforInjection500mg
PowderforInjection
11g
6.2.1.7Cefazolin PS,T
5.5 Lorazepam PS,T Tablet
1mg
Tablet2mg
Injection2mg/ml
S,T Tablet200mg
Tablet400
mg
6.2.1.8Cefixime
Oralliquid50mg/5ml
ROralliquid100mg/5m
PowderforInjection250mg
PowderforInjection500mg
PowderforInjection19
6.2.1.10CeftazidimestS,T PowderforInjection250mg
PowderforInjectiong
PowderforInjection250mg
PowderforInjection500mg
PowderforInjection1g
PowderforInjection29
Capsule250
mg
27i t Capsule.sung
te
OralLiquld125mg
a
PowderforInjection
z
6.2.1.13Piperacillin(A)+Ti
PowderforInjection
azobactam(B)snfisei1g A):t125mgp
PowderforInjection
2g(A)
+250
mg
(B
Powderfor
Injectión
4g(A)+500
mg(B)
5.6 s,TMagnesium
sulphate
Injection500mg/ml
6.2.1.9Cefotaxime S,T
Tablet30mgTablet60mg
Oralliquid20mg/5ml
5.7 PhenobarbitonePS,T
S,T Injection200mg/ml
Tablet50mg
Tablet100mg
Tablet300mg
ERTablet300mg
Oralliquid30mg/5
m
Oralliquid
125
mg/5ml
Injection25mg/ml
niection50mgml
Tablet200mg
Tablet300mg
CRTablet300mg
Tablet500mg
CRTablet500mg
Oralliquid200mg/5ml
Injection100mg/ml
Section6..Antiinfectivemedicines
Phenytoin PS,T
6.2.1.11CeftriaxoneS,T
6.2.1.12CloxacilinPs,T
PST5.9 Sodium
valproate
6.2.2:Otherantibacterlals
6.2.2.1AzithromycinPS,TTablet250mg
6.1
Anthelminthics
Tablet500
mg
Oralliquid200mg/5m
Powderfor
Injection
500mg
6:1.1
Intestinalanthelminthics
6111
AlbendazolePS,T
Tablet400
mg
Oralliquid200mg/5ml
Tablet100mg
Oralliquid100mg/5ml
6.2.2.2CiprofloxacinPS,T Tablet250mg
Tablet500mg
Oral
liquid250
mg/5m
Injection200
mg/10Um
Tablet250
mg
lablet
500
mg
Oralliquid125mg5
Tablet400mg(A
80
mg(B)
Tablet800
mg(A)+
6.11.2
MebendazolePS,T
6.1.2:Antifilarial
6.2.2.3ClarithromycinS,T
Tablet50mg
Tablet100mg
Oralliquid120mg/5ml
6.1.2.1
Diethylcarba-PS,T
mazine
6.1.3:
Anti-schistosomal&anti-trematodalmedicine
S,T
6.2.2.4Co-trimoxazole
[Sulphamethoxa-
zole(A)4
Tablet600mg
6.1.3.1
Praziquantel

117. 543
NATIONALLISTOFESSENTIAL
MEDICINES
Dosageformandstrength Levelof
Healthcare
Dosageformandstrength
Levelof
Healthcare
MedicinesMedicines
60mg(B)
Oralliquid200mg(A)+
40mg(B)/5ml
6.3:Antifungalmedicines
Trimethoprim(B)]|
PowderforInjection50mg
AmphotericinBS,T
a)AmphotericinB
(conventional)
b)Lipid/Liposomal
AmphotericinB
6.3.1
Capsule100mg
DrySyrup50mg/5ml
PS,T
6.2.2.5
Doxycycline
Injection10mg/ml
Injection40mg/ml
P.S,T
Pessary100mg
Tablet100mg
Tablet150mg
Tablet200mg
Tablet400mg
Oralliquid50mg/5ml
Injection200mg/100ml
Tablet125mg
Tablet250mg
Tablet375mg
ClotrimazolePS,T
PS,T
6.2.2.6
Gentamicin
6.3.2
6.3.3Fluconazole
Tablet200mg
Tablet400mg
Oralliquid200mg/5ml
Injection500mg/100ml
PS,T
6.2.2.7
Metronidazole
Tablet100mg
Oralliquid25mg/5ml
PS,T s,T6.2.2.8
Nitrofurantoin
6.3.4GriseofulvinPS,T
PowderforInjection250mg
PowderforInjection500mg
PowderforInjection1g
6.2.2.9Vancomycin
Tablet500,000
IU
Pessary100,000IU
OralLiquid100,000IU/ml
6.3.5Nystatin PS,T
6.2.3:Antileprosymedicines
Capsule50mg
Capsule100mg
6.2.3.1
Clofazimine P.S,T
6.4Antiviralmedicines
Tablet25mg
Tablet50mg
Tablet100mg
6.4.1:Antiherpesmedicines
PS,T
6.2.3.2Dapsone PS,T
Tablet200mg
Tablet400mg
PowderforInjection250mg
PowderforInjection500mg
Oralliquid400mg/5ml
6.4.1.1Acyclovir
Capsule150mg
Capsule300mg
623.3Rifampicin PS,T
6.2.4Antituberculosismedicines
6.4.2:AntiCytomegalovirus(CMV)medicines
S,T
6.2.4.1CapreomycinPS.
T PowderforInjection
1
g9
Capsule250mg
PowderforInjection500mg
nls 6.4.2.1Ganciclovir
Capsule125mg
Capsule250mg
6.2.4.2CycloserinePS.T
6.4.3:Antiretroviralmedicines
6.4.3.1Nucleosidereversetranscriptaseinhibitors
624.3Ethambutol Tablet200mg
Tablet400mg
Tablet600mg
Tablet800mg
P.S,T
Tablet60mgS,T
ti
Tablet300mg
6.4.3.1.1Abacavir
6.4.3.1.2Abacavir(A)+S,T
Lamivudine(B)
Tablet60mg(A)+30mg(B)
Tablet600mg(A)+
300mg(B)
6.2.4.4Ethionamide
P,S,T Tablet125mg
Tablet250mg
62.4.5Isoniazid PS,T Tablet50mg
Tablet100mg
Tablet300mg
Oralliquid100mg/5ml
PowderforInjection500mg
PowderforInjection750mg
PowderforInjection1g
Tablet250mg
Tablet500mg
Tablet750mg
6.4.3.1.3Lamivudine
(A)+S,T
Nevirapine(B)+
Stavudine(C)
DispersibleTablet30mg(A)
+50mg(B)+6mg(C)
Tablet150mg(A)+
200mg(B)+30mg(C)
6.2.4.6
Kanamycin
6.4.3.1.4Lamivudine(A)+S,T
Zidovudine(B)
Tablet30mg(A)+60mg(B)
Tablet150mg(A)+
300mg(B)
P.S,T
62.4.7
Levofloxacin
6.4.3.1.5Stavudine
(A)+S,T
Lamivudine
(B)
DispersibleTablet6mg(A)
+30
mg(B)
Tablet30mg(A)+
150mg(B)
PS,T
62.4.8
Linezolid
62.4.9
Moxifloxacin
PS,T Tablet600mg
6.4.3.1.6Tenofovir(A)+
Lamivudine(B)
S,T Tablet300mg(A)+
300mg(B)
Tablet300mg(A)+
300mg(B)+600mg(C)
PS
Tablet200mg
Tablet400mg
6.4.3.1.7
Tenofovir(A)+
Lamivudine(B)+
Efavirenz(C)
624.10
Para-
PS,T
aminosalicylic
acid
Tablet500mgGranules
(Aslicensed)
S,T
$2.4.11
Pyrazinamide
Tablet300mg
Oralliquid50mg/5ml
Tablet60mg(A)+
30mg(B)+50mg(C)
Tablet300mg(A)+
150mg
(B)+200mg(C)
6.4.3.1.8Zidovudine S,T
Tablet500mg
Tablet750mg
Tablet1000mg
Tablet1500mg
Oralliquid250mg/5ml
Capsule150mg
Capsule150
mg
Capsule300mg
Capsule450mg
Capsule600mg
Oralliquid100mg/5
m
PowderforInjection750mg
Powderfor
Injection1g
PS,T
6.4.3.1.9Zidovudine(A)+S,T
Lamivudine(B)+
Nevirapine(C)
524.12
Rifabutin
24.13
Rifampicin
S,T
6.4.3.2:Non-nucleosidereverse
transcriptaseinhibitors
P.S,T
Tablet50mg
Tablet200mg
Tablet600mg
6.4.3.2.1Efavirenz S,T
24.14
Streptomycin
PS,I
S,T DispersibleTablet50mg
Tablet200mg
Oralliquid50mg/5ml
6.4.3.2.2Nevirapine

118. 544
ESSENTIALMEDICINESANDCOUNTERFEITMEDICINES
LevelofDosageformandstrength
Healthcare
Medicines LevelofDosageformandstrength gMedicines
Healthcare
Tablet150
mg
Oralliquid50mg/5ml
Capsule150mg
Capsule300mg
Tablet2.5mg
Tablet7.5mg
Tablet15mg
6.4.3.3:Integraseinhibitors 6.5.3.1.4Chloroquine PS,T
6.4.3.3.1Raltegravir S,T Tablet400mg
6.4.3.4Proteaseinhibitors
6.5.3.1.5Clindamycin PS,T
6.4.3.4.1Atazanavir(A)+S,T Tablet300mg(A)+
100mg(B)Ritonavir(B) 6.5.3.1.6Primaquine PS,T
6.4.3.4.2Darunavir S,T Tablet600mg
6.4.3.4.3Lopinavir(A)+
Ritonavir(B)
Tablet100Omg(A)+25mg(B)
Tablet200mg(A)+50mg(B)
Oralliquid400mg(A)+
100mg(B)/5ml
S,T
PS,T Tablet300mg
Injection300mg/ml
6.5.3.1.7Quinine
6.5.3.2:Forprophylaxis
6.5.3.2.1Mefloquine Tablet250
mg
*Onlyforuseas
chemoprophylaxisforlong
termtravellers!hkemilitary
andtraveltroops,travelling
fromlowendemictohigh
endemicarea.
6.4.3.4.4Ritonavir S,T Tablet100mg
T
6.4.4:MedicinesforhepatitisBandhepatitisC
6.4.4.1Entecavir S,T Tablet0.5mg
Tablet1mg
6.4.4.2Pegylated S,TInjection180mcg
interferonalfa2a
Pegylated
interferonalfa2b
6.5.4:Antipneumocystosisand
antitoxoplasmosismedicines
Injection80mcg
Injection100mcg
Injection120mcg
Capsule200mg
Tablet400mg
S,T
6.5.4.1Co-trimaxazole
(Sulphametho-
xazole(A)+
Trimethoprim(B)]
Tablet400mg(A)+
80
mg(B)
Tablet800mg(A)+
160mg(B)
Oralliquid200mgA)
40mg(B)/5ml
PS,T
6.4.4.3Ribavirin S,T
6.4.4.4Sofosbuvir S,T
6.4.4.5Tenofovir S,T Tablet300mg
6.5:AntiprotozoalMedicines
6.5.1:Antiamoebicandantigiardiasismedicines
6.5.4.2Pentamidine S,TPowder
forInjection200mg
Section7:Antimigrainemedicines
7.1:Fortreatmentofacuteattack
AcetylsalicylicPS,T
acid
i
6.5.1.1Diloxanide PS,T Tablet500
mg
furoate
6.5.1.2MetronidazolePS,T
u
1Tablet40Omg
Tablet200mg 7.1.1
Tablet300mgto500mg
Effervescent/Dispersible
Entericcoated
Tablet300mgto500
mg
Tablet500
mg
Tablet650
mg
Tablet25
mg
Tablet50
mg
Injection6
m
r E
Injection500mg/100ml
Oralliquid200mg/5ml1
6.5.2:Antileishmaniasismedicines 7.1.2ParacetamoldPS,T
6.5.2.1AmphotericinBS,T
aAmphotericinB
(conventional)
b)Lipidiposomal
AmphotericinB
6:5.2.2Miltefösine PS;T
PowderforInjection50
mg
7.1.3SumatriptaniRS,T
isiai,
.13 0.5
m
R.2Forprophylaxis.
Capsule10
mg
Capsule50mg
Injection375mg/il
7.2.1FlunarizineiRS,T Tablet5mg
Tablet10mg
Tablet10mg
Tablet40mg
Tablet80
mg
6:5.2.3Paromomycin PS,T
7.2.2Propranolol.iu,PS,T
6.5.3Antimalarialmedicines
6.5.3.For curativetreatment
t
6.5.3.1.1Artemether(A)+PS,T Tablet20mg(A)+120mg(B) Sectlon8:Antineoplastic/immunosuppressivesang
medlcinesusedinpalliativecare
8.1Antineoplasticmedicines
5-FluorouracilT
6-MercaptopurineT
Lumefantrine(B Tablet40mg(A)+
240mg(B):
Tablet80mg(A)+
480mg(B)
Oralliquid80
mg(A)
480mg(B)/5ml
PowderforInjection60mg
PowderforInjection120mg
Combipack(A+B)
ITablet25mg(A)+1:Tablet
(250mg+12.5mg)(B)
1Tablet50mg(A)+1Tablet
(500mg+25mg)(B)
1Tablet100
mg
(A)+
1Tablet(750mg+
37.5mg)(B)
1Tablet150mg(A)+
2Tablet(500mg+25mg)(B)
1Tablet200mg(A)t
2Tablet(750mg+
37.5mg)(B)
8.1.1
T Injection250mg/5m
Tablet50
mg
Powderforlnjection0.5
mg
Capsule10
mg
8.1.2
8.1.3ActinomycinD
6.5.3.1.2Artesunate PS,T 8.1.4
6.5.3.1.3Artesunate(A)+PS,T
Sulphadoxine
Pyrimethamine(B)
All-trans
retinoicacid
ArsenictrioxideT
Bleomycin
8.1.5
Injection1mg/ml
Powderfor
Injection15
units
PowderforInjection2mg
Tablet15mg
Injection3mg/m
Tablet500ms
Injection10mg/ml
Tablet2mg
Tablet5
mng
Injectlon1mg/ml
8.1.6
T
8.1.7Bortezomib
8.1.8CalciumfolinateT
Capecitabine
8.1.10Carboplatin
8.1.11Chlorambucil
8.1.9
8.1.12Cisplatin
T

119. 545NATIONAI.LISTOFESSENTIAL.
MEDICINES
LevelofDosageformandstrenglh
Healthcare
IevelofDosageformandstrength
Medicines Medicines
Healthchre
**
Capsule10mg
Capsule25mg
Capsule50mg
Capsule100mg
Oralliquld100mg/ml
Injection50mg/ml
Tablet250mg
Tablet500mg
.13
Cyclophospha-
mide
Tablet50mg
Tablet200mg
PowderforInjection500mg
8,3.2CyclosporineT
Injection100mg/ml
PowderforInjection500mg
Powderfor
Injection1000mg
.14
Cytosine
arabinoside
Mycophenolate
mofetil
8.3.3 T
PowderforInjection500mg
PowderforInjection200mg
T
.15Dacarbazine
Capsule0.5mg
Capsule
1mg
Capsule2mg
8.3.4Tacrolimus
16
Daunorubicin Injection5mg/ml
PowderforInjection20mg
PowderforInjection80mg
8.4:Medlclnesusedinpalllativecare
Allopurinol T
17
Docetaxel
8.4.1
Tablet100mg
.18Doxorubicin Injection2mg/ml
8.4.2Amitriptyline
Tablet10mgTablet25mg
Capsule50mg
Capsule100mg
Injection20mg/ml
19Etoposide
Tablet0.5mg
Injection4mg/ml
8.4.3DexamethasoneT
Tablet2mg
Tablet5mg
Injection5mg/ml
20Gefitinib T Tablet250mg 8.4.4Dtazepam
PowderforInjection200mg
PowderforInjection
1
g
21Gemcitabine
8,4.5Filgrastim Injection300meg
22IfosfamideT
PowderforInjection1g
PowderforInjection2g Capsule20mg
Tablet1.5mg
Tablet5mg
Injection5mg/ml
8.4.6Fluoxetine
Tablet100mg
Tablet400mg
23Imatinib T 8.4.7Haloperidol T
Powderfor
Injection5000KU.
Powderfor
Injection10000KU
24LAsparaginaseT
8.4.8Lactulose T Oral
liquid10
g/15ml
8.4.9Loperamide TTablet2mg
8.4.10MetaclopramideTTablet
10mg
25Melphalan Tablet2mg
Tablet5mg
Oralliquid5mg/5ml
Injection5mg/ml
26
Mesna Injection100mg/ml
8.4.11Midazolam Injection
1mg/ml
7Methotrexate Tablet2.5mg
Tablet10mg
Tablet20mg
Tablet30mgSR
8.4.12Morphine
Tablet5
mng
ora
1 Tablet10mg
Injection50mg/ml
Injection5mg/ml
Injection30mg/5ml
Injection100mg/16.7ml
Capsule50mg
Tablet4mg
Tablet8mg
Oralliquid2mg/5ml
Injection2mg/ml
8.4.13Ondansetron S,T
8Oxaliplatin
9
Paclitaxel
Capsule50mg
t43E5*a 5tCapsule100mg
0Procarbazine 8.4.14Tramado
Rituximab Injection10mg/ml
epodtei.f.tInjection50mg/ml
Capsule20mg
Capsule100mg
Capsule250mg
2Temozolomide T
8.4.15ZoledronicacidT PowderforInjection4mg
Section9:Antiparkinsonismmedicines
Capsule50
mng
Capsule100mg
Tablet100mg(A)+
10mg(B)
Tablet100mg(A)+
25mg(B)
CRTablet100mg(A)+
25mg(B))
CRTablet200mg(A)+
50(B)mng
3
ThalidomideT 9.1 Levodopa(A)+PS,T
Carbidopa(B)
Trastuzumab Injection440mg/50ml
VinblastineT
Injection
1mg/ml
VincristineT
Injection
1mg/ml
ormonesandantihormonesusedincancertherapy
BicalutamideT
Letrozole
T
Prednisolone
Tablet50mg s sn.Tablet250mg(A)+
Tablet2.5
mg
Tablet10mg
Tablet20mg
Tablet40mg
Oralliquid5mg/5
m
Oralliquid15mg/5ml
Injection20mg/2ml
Tablet10mg
Tablet20mg
idgi ir25
mg(B)
TrihexyphenidylPS,T Tablet2mg
Section10:Medicinesaffectingblood
10.1:Antianaemiamedicines
9.2
S,T
S,T Injection2000IU/ml
Injection10000IU/ml
10.1.1Erythropoietin
Ferroussalts PS,T Tabletequivalentto60mg
ofelementaliron
Oralliquidequivalentto
25mgofelementaliron/ml
amoxifen
10.1.2
3Immunosuppressive
medicines
Azathioprine
T
Tablet50mg

120. 546
ESSENTIALMEDICINES
ANDCOUNTERFEITMEDICINES
Medicines LevelofDosageformandstrengthLevelofDosageformandstrength
Healthcare
Medicines
Healthcare
12.1.2Clopidogrel PS,T Tablet75mgTablet45mgelementaliron
(A)+400
mcg(B)
Tablet100mgelemental
iron(A)+
500
mcg(B)
Oralliqiud20mgelemental
iron(A)+100mcg(B}/ml
10.1.3Ferroussalt(A)+PS,T
Folicacid(B) Tablet30mg
Tablet60mg
SRTablet90mg
12.1.3Diltiazem PS,T
T Injection5mg/ml
10.1.4Folicacid PS,T Tablet5mng
12.1.4Glyceryl PS,T Sublingualtablet0.5mg
Injection
1mg/mlHydroxoco
balamin
10.1.5 PS,T trinitrate
S,T Injection5mg/ml
10.1.6Hydroxyura PS,T Capsule500mg
Tablet10mg
Tablet20mg
SRTablet30mg
SRTablet60mg
12.1.5Isosorbide-5-PS,T
10.1.7Ironsucrose S,T Injection20mg/ml
mononitrate"
10.2Medicinesaffectingcoagulation
Injection40mg/0.4ml
Injection60mg/0.6m
Injection1000IU/ml
Injection50001U/ml
10.2.1Enoxaparin T
IsosorbidePS,T
dinitrate
Tablet5mg
Tablet10mg
12.1.6
10.2.2Heparin S,T
Tablet25mg
Tablet50
mg
SRTablet25
mg
SRTablet50
mg
12.2:Antiarrhythmicmedicines
12.1.7Metoprolol PS,T
Tablet10mmg
Injection10mg/ml
Injection10mg/ml
Tablet500mg
Injection100mg/ml
Tablet1mg
Tablet2mg
Tablet3mg
Tablet5mg
PhytomenadionePs,T
(VitaminK,)
Protamine
10.2.3
2.4 S,T
10.2.5TranexamicacidP.S,T
10.2.6Warfarin S,T 12.2.1Adenosine S,T Injection3mg/ml
Tablet100mg
Tablet200mg
Injection50
mg/ml
12.2.2Amiodarone S,T
Section11BloodproductsandPlasmasubstitutes
EsmololT Injection10mg/ml
LignocaineS,T
12.2.3
11.1:BloodandBloodcomponents
Injection2%(Preservative
freeforIVuse)
12.2.4Allformsofthefollowingasapprovedbylicensingauthorityare
consideredasincludedinNLEM,However,consideringtheprocess,
technologyandotherrelevantaspects,theyshouldbeconsidered
differentlyforpurposessuchasprocurementpolicy,pricingetc.
111.1
Tablet40mg
Tablet80mg
Injection2.5
mg/ml
12.3:Antihypertensivemedicines
Tablet2.5mg
Tablet5
mg
Tablet10mg
PS,TTablet
50mg
Tablet100
mg
12.2.5VerapamilST
As
licensedFreshfrozenS,T
plasma
11:1:2Plateletrich S,T
plasma
RedbloodcellsS,T
11.14Wholeblood S,T
Aslicensed
12.3.1Amlodipinesin,PS,T
11.1.3
Aslicensed
Aslicensed
11.2Plasmasubstitutes
12.3.2Atenolol
:
11:2.1
Dextran-40 S,T Injection10%
Tablet2.5mg
Tablet5
mg
Tablet12.5
mg
thiazide a
Tablet25
mg
Injection5
mg/ml
Tablet250mg
Tablet500
mg
Tablet2.5mg
Tablet5mg
12.3.3Enalapril PS,T
11.3Plasmafractionsforspecificuse
Incaseof
coagulationfactorsandotherbloodproducts,irrespectiveof
variationinsource,allformsoftheseproductsasapprovedby
licensingauthorityareconsideredasinclidedinNLEM.However,
considering"thesource,prOcess,technologyandotherrelevant
aspects,theyshouidbeconsidereddifferentlyforpurposessuchas
12.3.4Hydrochloro- BS,T
12.3.5Labetalol PS,T
MethyldopaPS,Tprocurementpolicy,pricingetc.
Coagulation
factorIX
12.3.6
11.3.1
S,T PowderforInjection600IU
12.3.7Ramipril3 PS,T
S,TCoagulation
factorVIl
PowderforInjection250
1U
PowderforInjection500IU
11.3.2
12.3.8SodiumsTwtdiInjection
10mg/ml
AslicensedCryoprecipitateS,T
Section12:Cardiovascularmedicines
12.1Medicinesusedinangina
11.3.3 nitroprusside
Tablet20mg
Tablet40mg
Tablet80
mg
12.3.9TelmisartanPS,T
Tablet75mgEffervescent/
Dispersible/Entericcoated
Tablet75mg
Tablet100mg
Effervescent/Dispersible/
Entericcoated
Tablet100mg
Tablet150mg
Effervescent/Dispersible/
Entericcoated
Tablet150mg
12.1.1
AcetylsalicylicPS,T
12.4:Medicinesusedinshockandheartta
Tablet0.25
mg
Oralliquid0.05
mg
Injection0.25
mg/mi
Injection50
mgm
12.4.3DopamineS.Tgnjection
NoradrenalineS,TInjection2
mgm
àcid
12.4.1DigoxinS.T
12.4.2Dobutamine
S,1
12.4.4

121. 547
NATIONALLISTOFESSENTIAL
MEDICINES
Dosageformandstrength
Levelof
Healthcare
Medicines Dosagetormandstrength Medicines
Levelof
Healthcare
12.5:Antithromboticmedicine
(Cardiovascular/Cerebrovascular)
PS.T
15.2Radiocontrastmedia
Oralliquid100%
w/wv
Oralliquid250%w/v
15.2.1BariumsulphateS,T
12.5.1
Acetylsalicylic
acid
Tablet75mg
Efervescent/Dispersible/
EntericcoatedTablet75mg
Tablet100mg
Effervescent/Dispersible/
Entericcoated
Tablet100mg
Tablet150mg
Effervescent/Dispersible/
Entericcoated
Tablet150mg
15.2.2Gadobenate
Injection529mg/ml
Injection140to350mg
iodine/ml
15.2.3lohexol S,T
Injection60%w/v
Injection76%w/v
S,TMeglumine
diatrizoate
15.2.4
Section16:Dialysissolutions
S,T Aslicensed
Haemodialysis
fluid
16.1
PowderforInjection20mg
PowderforInjection50mg
S,T Aslicensed
Intraperitoneal
dialysissolution
12.5.2Alteplase 16.2
Injection1000IU/ml
Injection5000IU/ml
12.5.3Heparin S,T Section17:Disinfectantsandantiseptics
17.1:Antiseptics
S,T Injection750,000
1U
Injection15,00,000IU
Solution20%
(Concentratefordilution)
12.5.4Streptokinase
17.1.1Cetrimide RS,T
12.6Hypolipidemicmedicines
Solution5%
(Concentratefordilution)
17.1.2ChlorhexidinePS,T
Tablet10mg
Tablet20mg
Tablet40mg
12.6.1Atorvastatin PS,
17.1.3Ethylalcohol
(Denatured)
PS,T Solution70%
Section13:Medicinesusedindementia
PS,T Solution6%
Tablet5mng
Tablet10mg
17.1.4Hydrogen
peroxide
13.1DonepezilS,T
Topialpreparation
0.25%to2%
PS,T17.1.5Methylrosani-
liniumchloride
(GentianViolet)
Section14
:
Dermatologicalmedicines(Topical)
14.1Antifungalmedicines
141.1ClotrimazolePS,T Cream1% 17.1.6PovidoneiodinePS,T Solution4%to10%
14.2Antiinfectivemedicines 17.2:Disinfectants
14.2.1Framycetin 17.2.1BleachingpowderPS,T Containingnotlessthan
30%w/wofavailable
chlorine(asperI.P)
PS,T Cream0.5%
14.2.2Fusidicacid PS,T Cream2%
14.2.3Methylrosani Topialpreparation
0.25%to2%
PS,T
17.2.2GlutaraldehydeS,T 5Solution2%
liniumchloride
(GentianViolet)
14.2.4
PovidoneiodinePS,T
17.2.3Potassium PS,T Crystalsfortopicalsolution
Solution4%to10%
permanganate
14.2.5
Silver PS,T Cream1%
Section18:Diuretics
sulphadiazine Furosemide PS,T Tablet40mg
Oralliquid10mg/ml
Injection10mg/ml
18.1
4.3:Antiinflamatoryandantipruriticmedicines
14.3.1
Betamethasone Cream0.05%
Cream0.1%
PS,T
Hydrochloro
thiazide
Tablet25mg
Tablet50mg
18.2 PS,T
14.3.2
Calamine Lotion(AsperIP).
14.4:Medicinesaffectingskin
differentiationandproliferation
PS,T
18.3 Mannitol PS,T Injection10%
Injection20%
Tablet25mg
Tablet50mg
18.4SpironolactoneRS,T
4.4.1BenzoylperoxidePS,T
14.4.2
Coaltar
144.3
Podophyllin
resinS
144.4
Salicylic
acid
Gel2.5%
PS,T Solution5%
Section19:Ear,noseandthroatmedicines
Solution10%to25%
Ointment6%
14.5:Scabicidesandpediculicides
19.1Budesonide PS,T
145:
Permethrin
PS,TLotion1
NasalSpray50mcg/dose
NasalSpray100mcg/dose
PS,T
CiprofloxacinPs,T
ClotrimazolePs,T
XylometazolinePS,T
19.2 Drops0.3%
19.3 Drops1%
Cream5%
14.6::Miscellaneous
19.4
6.1Glycerin
6.2WhitePetrolatum
PS
Nasaldrops0.05%
Nasaldrops0.1%
Section20:Gastrointestinal
medicines
PS,TOral
Liquid
Jelly100%
Section15Diagnosticagents
15.1:Ophthalmicmedicines
Eyedrop1%
Eyedrop4%
Eyedrop1%
20.1Antiulcermedicines
20.1.1Omeprazole RS,T
Capsule10mg
Capsule20mg
Capsule40mg
Powderfororalliquid20mg
15.1.1
Fluorescein
5.12
LignocaineST
513
Tropicamide
ST
sT
20.1.2PantoprazoleS,T
Injection40mg

122. ESSENTIALMEDICINESANDCOUNTERFEITMEDICINES
Medicines LevelofDosageformandstrength
Healthcare
Medicines Levelof
Healthcare
Dosageformandstrength
RanitidinePS,T Tablet150mg 21.2.3:Barriermethods
Oralliquid75mg/5ml
Injection25mg/ml
Oralliquidlg
21.2.3.1Condom PS,T Asperthestandards
prescribedinScheduleR
ofDrugsandCosmetics
rules,1945
Sucralfate S,T
20.2Antiemetics
Domperidone 21.3:EstrogensTablet10mg
Oralliquid1mg/ml
PS,T
Tablet0.01mg
Tablet0.05mg
Tablet0.75mg
21.4Medicinesusedindiabetesmellitus
21.3.1EthinylestradiolPS,T
MetoclopramidePS,T Injection5mg/ml
Tablet4mg
Oralliquid2mg/5ml
Injection2mg/ml
20.3Antiinflammatorymedicines
Tablet400
mg
Suppository500mg
RetentionEnema
Ondansetron S,T
21.3.2LevonorgestrelPS,T
21.4.1.1Glimepiride
21.4.1.2Insulin(Soluble)PS,T
21.4.1.3Intermediate
Acting(NPH)
21.4.1nsulinsandotherantidiabeticagents
Tablet1mgTablet2mg
Injection40
1U/ml
Injection401U/ml
PS,T
5-aminosalicylicS,T
acid
PS,T
20.4:Antispasmodicmedicines Insulin
PS,TTablet
500
mg
Tablet750mg
1Dicyclomine 21.4.1.4MetforminTablet10mg
OralSolution10mg/5ml
Injection10mg/ml
Tablet10mg
Injection20mg/ml
PS,T
1}s atfaiii
nlablet1000mg(Immediate
andcontrolledrelease
Hyoscine
butylbromide
2 PS,T
PS,T Injection40IU/ml21.4.1.5PremixInsulin
30:70Injection
(Regular:NPH)20.5:Laxatives
PS,T Tablet5mg
Suppository5mg
.1Bisacodyl
21.4.2Medicinesusedtotreathypoglycemia
Injection25%
21.5:OvulationInducers
EsTablet50mg
21.4.2.1Glucose PS,T
.2Ispaghula PS,T Granules/Husk/Powder
.3Lactulose S,T Oralliquid10g/15ml
21.5.1Clomiphene T
20.6:Medicinesusedindiarrhoea
TR92 gert;*Tablet100
mg
6.1OralrehydrationPS,T
salts
6.2Zinc
sulphate
Aslicensed
21.6:Progestogensei
.
MedroxyprogesPS,T Tablet5
mg
Tablet10mg
PS,T Tablet.5m9
21.7:Thyroidandantithyroidmedicines
Tablet5
mg
Tablet10mg
21.6.1
PS,T DispersibleTablet20mg
teroneacetate
20.7:Othermedicines 21.6.2Norethisterone
71Somatostatin PowderforInjection3mg
Section21:Hormones,otherendocrine
2medicines
andcontraceptives
21.7.1CarbimazolePS,T
21.7.2Levothyroxine
PS,T
Tablet
12.5mcgto150mcg
(Severalstrengthsare
availableinmarketsuch
as
12.5,25;50,62.5,75,88,
zs1egih bthyi100,112
mcg.Theretore
wasconsideredtogivea
rangeofavailable,
21.1:
Adrenalhormonesandsyntheticsubstitutes
1.1DexamethasoneSTTablet
0.5mg
Injection4mg/ml
Injection1000
IU
Injection5000
IUU
Tablet5
mg
Tablet10mg
Injection100mg/ml
Tablet8
mng
Tablet16mg
Tablet32mg
Injection40mg/ml
1.2Humanchorionic:T
gonadotropin
13
HydrocortisonePS,T
strengths)
Section22Immunologicals
:
14
Methylpred-
nisolone
S,T
Incaseofthesebiologicals,irrespectiveofvariationin
soure
compositionandstrengths,allthepröductsofthe
same
vaccinea
mmunoglobulin,asapprovedbylicensingauthority
areconsiaer
includedinNLEM.However,consideringthesoureo
same
technologyandotherrelevantaspects,differentproductsotthesna
biologicalsshouldbeconsidereddifferentlyforpurposessu
PS,T Tablet5
mg
Tablet10mg
Tablet20mg
.1.5
Prednisolone as
procurementpolicy,pricingetc.
T2
21.2:Contraceptives 22.1:Diagnostic.agents
21.2.1:Hormonalcontraceptives
Tablet0.03mg(A)+
0.15mg(B)
Tuberculin,ir:PST
PurifiedProtein
derivative
22.1.1
.2.1.1EthinylestradiolPS,T
(A)+
Levonorgestrel 22.2:Seraandimmunoglobulins(Liquid/Lyophillzea
1.2.1.2EthinylestradiolPS,T
(A)+
Norethisterone
Tablet0.035mg(A)+
1mg(B)
22.2.1Anti-rabiesPS,T
immunoglobulin
22.2.2Anti-tetanusBS,T:3
immunoglobulin21.2.2ntrauterinedevices
22.2.3Anti-D S,T
Contains52mgof
Levonorgestrel
T
1.2.2.1Hormone
releasingIUD
immunoglobulin
22.2.4DiphtheriaPS,T
antitoxin
PS,T Aslicensed
1.2.2.2IUDcontaining
Copper

123. 549
NATIONALLLISTOFESSENTIAI
MLI
Medicines LevelofDosageformandstrength
Medicines LevelofDosageformandstrenythHealthcare
HealthcareS,T22.2.5
HepalitisB
immunoglobulin
T
Drops0.6%
Drops5%
25.1.6PovidoneiodinePS,T
22.2.6Humannormal
immunoglobulin
25.2:Antiinílammatorymedicine
Drops0.1%
Drops1%
25.2.1PrednisolonePS,T
22.2.7Snakevenom
antiserunm
a)Soluble/liquid
polyvalent
b)Lyophilized
polyvalent
RS,T
25.3Localanaesthetics
PS,T
25.3.1Proparacaine Drops0.5%
25.4Mioticsandantiglaucomamedicines
PS,T
22.3:Vaccines 25.4.1Acetazolamide Tablet250mg
Drops2%
Drops4%
25.4.2Pilocarpine PS,T
al
AllthevaccineswhichareunderUniversalImmunization
Programme
ofIndia(UIP)willbedeemedincludedinNLEM.Presently,
theUIPhasBCG,DPT,OPV,measles,HepatitisB,Japanese
encephalitis&PentavalentVaccines.
)Thenewvaccines,whichhavebeenapprovedbyNationalTechnicalAdvisoryGrouponImmunization(NTAGI)andplannedto
e
givenunderUIRwillbedeemedtobeincludedasandwhenlistednUIPThesevaccinesareinactivatedpoliovaccine(IPV),MeaslesRubella(MR)andRotavirusvaccine.
Infuture,thevaccineswhichareunderconsideration
,
ifandwhenncludedinUIP,willalsobedeemedincludedfromthedateofclusioninUIP.ThesearepneumococcalandHPVvaccines.
25.4.3TimololePS,T Drops0.25%
Drops0.5%
25.5Mydriatics
PS,T Drops1%
Ointment1%
25.5.1Atropine
25.5.2Homatropine PS,T Drops2%
Drops5%
Drops10%
25.5.3PhenylephrinePS,T
25.5.4Tropicamide
PS,T Drops1%
22.3.1:Foruniversalimmunisation
PS,T
P.S,T
25.6:Ophthalmicsurgicalaids
Hydroxypropyl
methylcellulose
2.3.1.1BCGvaccine
2.3.1.2DPT+Hib+
HepBvaccine
2.3.1.3
DPTvaccine
2.3.1.4
HepatitisB
25.6.1
T Injection2%
25.7Miscellaneous
PS,T
PS,T
25.7.1Carboxymethyl
BS,T
cellulose
Drops0.5%
Drops
1
%
vaccine
.3.1.5Japanese
encephalitis
vaccine
PS,T
Section26:OxytocicsandAntioxytocics
26.1:Oxytocicsandabortifacient
Tablet0.5mg
Gel0.5mg
Tablet0.125mg
Injection0.2mg/ml
26.1.1DinoprostoneS,T
3.1.6Measles
vaccine
3.1.7Oralpoliomyelitis
PS,T
PS,T
Vaccine
26.1.2Methylergo
PS,T
3.1.8
TetanustoxoidPS,T
metrine
26.1.3Mifepristone
26.1.4Misoprostol
Tablet200mg
22.3.2:ForSpecificGroupofIndividuals
3.2.1Rabiesvaccine
PS,T
Tablet100mcg
Tablet200mcg
T
ction23
:
Musclerelaxantsandcholinesteraseinhibitors
26.1.5Oxytocin
S,T Injection5IU/ml
njection101U/ml
26.2:Medicinesusedinpre-termlabour
Atracurium
Injection10mg/ml
Tablet5mng
Tablet10
mg
Tablet20mg
S,T
Baclofen
S,T
26.2.1Betamethasone
PS,T
26.2.2Nifedipine
S,T
Section
27:Psychotherapeutic
medicines
27.1:MedicinesusedInpsychotic
disorders
Injection4mg/nl
Neostigmine
Tablet10ng
Tablet15mg
Injection0.5mg/ml
Injection50mg/ml
PowderforInjection4mg
PowderforInjection10mg
S,T
Succinylcholine
S,T
Vecuronium
S,T
27.1.1Clozapine
Tablet
25mg
Tablet50mg
Tablet
100mg
T
Section24Medicinesforneonatalcare
Injection0.5mg/ml
Oralliquid20mg/ml
Injection20mg/ml
Suspensionfor
Alprostadil
27.1.2FluphenazineS,T
DepotInjection25mg/ml
Caffeine
27.1.3Haloperidol
S,T Tablet
5mg
Tablet
10mg
Tablet
20mg
Oralliquid2mg/5ml
S,T
Surfactant
5,T
intratrachealinstillation
27.1.4Risperidone
PS,T
As
licensed)
ection25OphthalmologicalMedicines
25.1:Anti-infectivemedicine
3
PS,TOintment3%
Ciprofloxacin
PS.T Drops0.3%
Ointment0.3%
Ointment0.5%
Drops0.3%
Drops5%
Tablet1mg
Tablet2tng
Tablet4ng
Oralliquid1
mg/ml
27.2:Medicines
usedinmooddisorders
27.2.1Medicinesusedindepressive
disorders
1
Acyclovir
27.2.1.1Amitriptyline
PS,T
Erythromycin
Ps,T
Gentamicin
PSTNatamycin
PS,T
Tablet10mg
Tablet
25mg
Tablet
50mg
Tablet
75mg
WENINHaNTTT

124. 550
ESSENTIALMEDICINESANDCOUNTERFEITMEDICINES
Medicines LevelofDosageformandstrength
Medicines LevelofDosageformandstrength
HealihcareHealthcare
Tablet5mg
Tablet10mg
Tablet20mg
Section29:Solutionscorrectingwater,electrolyte
disturbancesandacid-basedisturbances
27.2.1.2EscitalopramS,T
Injection5%
Injection10%
Injection25%
Injection50%
29.1 Glucose PS,T
Capsule10mg
Capsule20mg
Capsule40mg
Capsule60mg
27.2.1.3Fluoxetinee PS,T
Glucose(A)+
Sodium
Injection5%(A)+
0.9%(B)
29.2 RS,T
27.2.2:MedicinesusedinBipolardisorders
chloride(B)
27.2.2.1Lithium S,T Tablet300mg
OralrehydrationPS,T
salts
29.3 Aslicensed
Tablet200mg
Tablet500mg
27.2.2.2SodiumvalproatePs,T
Potassium
chloride
Injection150mg/ml
Oralliquid500mg/5ml
29.4 PS,T
27.3MedicinesusedforGeneralized
AnxietyandSleepDisordeers
29.5 RingerlactateP.S,T Injection(asperIP)
Tablet0.25mg
Tablet0.5mg
Tablet1mng
27.3.1Clonazepam PS,T
PS,T Injection(asperIP)29.6Sodium
bicarbonate
27.3.2Zolpidem 29.7SodiumchloridePS,T Injection0.9%Tablet5mg
Tablet10mg
PS,T
S,T Injection0.45%
Injection3%27.4Medicinesusedforobsessive
compulsivedisordersandpanicattacks
29.3Miscellaneous
27.4.1Clomipramine
Waterfor PS,T Injection
Capsule10mg
Capsule25mg
Capsule75mg
S,T
29.3.1
Injection
30Vitaminsandminerals
Tablet100
mg
Tablet500
mg
27.4.2Fluoxetine
PS,T Capsule10mg
Capsule20mg
Capsule40mg
Capsule60mg
30.1 Ascorbicacid PS,T
(VitaminC)
Tablet250mg
Tablet500mg
30.2 Calcium PS,T
carbonateSection28:Medicinesactingontherespiratorytract
28.1:Antiasthmaticmedicines
30.3 Calcium
PS,T Injection100mg/ml
gluconate
28.1.1BudesonidePs,T Inhalation(MDI/DPI)
100
mcg/dose
Inhalation(MD/DPI)
200mcg/dose
Respiratorsolutionforuse
innebulizer0.5mg/ml
i
N
Respiratorsolutionforuse
in
nebulizermg/ml.
Inhalation(MDI/DPI)
Tablet10001U,
Tablet600001U
Oralliquid400IU/ml
NicotinamideaPs,T Tablet50
mg
PS,T Tablet10
mg
30.4CholealciferolPS,T
30.5
30.6Pyridoxine
*i2 9staeniisisbesaaadletu
mg
Tablet100mg
Budesonide(A)4PS,T
Formoterol(B)
s ies
100
mcg(A)
+6
mcg(B)
28.1.2
30.7 Riboflavin
PS,T Tablet5mg
30.8Thiamine PS,T
pa
Inhalation(MDI/DPI)
200
mcg
(A)+6mcg(B)
Inhalation(MDI/DPI)
*
Tablet100mg
injection100mg/ml
Capsule5000IU
Capsule50000IU
Capsule100000
1U
Oralliquid100000
IU/ml
Injection500001U/ml
30.9VitaminA7 PS,T
sikug k 400mcg
(A)+6
mcg(B)
28.1.3HydrocortisonePS,T Injection100mg
Injection200mg.
28.1.4Ipratropium PS,T Inhalation(MDI/DPI)
20mcg/dose
Respiratorsolutionforuse
innebulizer250mcg/ml
COUNTERFEITMEDICINES
AccordingtoWHO'sdefinition,adrug/medicine
counterteitifitisproducedwithan,intentiontocheat.
canincludemis-labelling(includingfudgingexpirydate
noactiveingredients,awrongingredient,orthe
co
ingredientinaninsufficientquantity.Bothbrandedal
genericproductscanbecounterfeited(3)
Sub-standardmedicines,alsocalled"outofspeciicat
medicinesareauthorizedmedicalproductsthattailto
eithertheirqualitystandardsorspecifications,orboth(
Falsifiedmedicalproductsthatdeliberately/fraudulenu
misrepresenttheiridentity,compositionorsource(
Unregistered/unlicensed
medicalproductsthatalo
undergoneevaluationand/orapprovalbythe
TNauo
Tablet2mg
Tablet4mg
Oralliquid2mg/5ml
Inhalation(MDI/DPI)
100mcg/dose
Respiratorsolutionforuse
innebulizer5mg/ml
28.1.5Salbutamol PS,T
PS,T Inhalation(MDI)
9mcg/dose
Inhalation(DPI)
18mcg/dose
28.1.6Tiotropium
MDI-Metereddoseinhaler
DPI-DryPowderinhaler

125. COUNTERFEITMEDICINES 551
lationAuthorityforthemarketinwhichtheyare
Regional
orused,subjecttopermittedconditions
Legislationformsthebasisfordrugregulation.Medicines
needtobesafe,effectiveandofgoodqualityinorderto
producetheexpectedtherapeuticeffect.Ensuringthese
propertiesrequiresthe
regulatoryauthoritieswiththenecessaryhumanandother
resourcesto
marketed/distribi
nationalorregionalregulationandlegislation(4).under
Falsifiedmedicalproductsmaycontainnoactive ofcompetentnationaldrugcreaati
ingredientorthewrongamount
o
ontaincornstarch,potatostarchorchalk.Somesub-
amorthemostcommonlyreportedsub-standardand
thewrongactivengredient,
of
rectactiveingredierTheyarealsocommonlyfound controlthemanufacture,importation,
distributionandsaleofmedicines.
andfalsifiedmedicalproductshavebeentoxinin
witheitherfatallevelsofthewrongactiveingredient
rothertoxicchemicals.Anti-malarialsandantibioticsare
Legislationmustbecomplementedwitheffectivelaw
enforcement.Governmentsneedtodevelopstrategiesto
reducecorruptionandcriminalactivityandpromote
intersectoralco-operationbetweenregulatoryauthorities,
police,customsservicesandthejudiciarytoeffectively
controlthedrugmarketandenforcedrugregulation.
falsifiedmedicalproducts.Bothgenericandinnovator
medicinescan
befalsified.Anestimated10percentmedical
Droductsinlowandmiddle-incomecountriesissub
standardorfalsified.
antimicrobialresistanceanddrug-resistantinfections(4).
Unregulatedwebsites,socialmediaplatformsand
smartphoneapplicationscanalsobedirectconduitsofsub-
standardandfalsifiedmedicalproducts.Riskstoconsumers
areincreasedwhentheyobtainmedicinesfromunlicensed
andunregulatedsources.Consumersshouldbecautiousof
thefollowing(4);
Theseproductscontributeto
QUALITYCONTROLIN
DRUGSECTORININDIA
1spamemailadvertisingmedicines;
2.lackofauthenticityornoverificationlogoorcertificate;
3.spellingmistakesandpoorgrammaronpackaging;
4.websitesthatdonotdisplayaphysicaladdressor
landline;and
websitesofferingprescriptiononlymedicineswithouta
prescription.
CentralDrugStandardControlOrganization(5
Thequalitycontrolofthedrugsmarketedinthecountry
isregulatedundertheDrugsandCosmeticsAct,1940and
Drugs&CosmeticsRules,1945.TheCentralDrugs
StandardControlOrganiza
ofDirectorGeneralofHealthServices,alongwithDrug
ControlOrganizationintheStatesareresponsibleforsafety,
efficacyandqualityofdrugs,theirimport,manufacture,
distribution,saleandstandards.
(CDSCO),intheDirectorate
TheCDScOattheCentreisheadedbytheDrugs
ControllerGeneral(India),intheDirectorateofDirector
GeneralofHealthServices,undertheMinistryofHealth
andFamilyWelfare.TheDrugControlOrganizationinthe
StatesisgenerallyheadedbytheStateDrugControllers
appointedbytheStateGovernments.
ldentifyingasub-standardorfalsifiedmedical
product
Somefalsifiedmedicalproductsarealmostvisually
identicaltothegenuineproductandverydifficulttodetect.
However,manycanbeidentifiedby(4):
ThemainfunctionsoftheCDSCOincludecontrolofthe
qualityofdrugsimportedintothecountry,coordinationof
theactivitiesoftheStates/UTsDrugControlAuthorities,
approvalofnewdrugsproposedtobeimportedor
manufacturedinthecountry,layingdownstandardsand
regulatorymeasuresandactingastheCentralLicense
ApprovingAuthorityinrespectofwholehumanbloodand
itsproducts,largevolumeparenterals(IVfluids),seraand
vaccinesandr-DNAproducts.Qualityofcosmetics
manufacturedandmarketedinthecountryarealso
regulatedundertheDrugsandCosmeticsAct.
TheCDScOhasanetworkofsixZonalOfficeslocatedat
Mumbai,Ghaziabad,Kolkata,Hyderabad,Ahmedabadand
Chennai,sixsub-zonalofticesand16portoffices
responsiblefor
7laboratories.TheZonalOfficersinspectthe
manufacturingunits,bloodbanksandapproveddrugtesting
laboratories,eitherjointlywithStateDrugControl
Authoritiesorindependently,anddeficienciesobserved
duringtheseinspectionsareinvariablybroughttothenotice
ofStateDrugControlAuthorities.Theportofficesmonitor
importandexportofdrugs.
examiningthepackagingforcondition,spellingmistakes
orgrammaticalerrors;
Checkingthemanufactureandexpirydatesandensuring
anydetailsontheouterpackagingmatchthedates
shownontheinnerpackaging;
ensuringthemedicinelookscorrect,isnotdiscoloured,
aegradedorhasanunusualsmell;
ucussingwithyourpharmacist,doctororother
edithcareprofessionalassoonaspossible
ifyoususpect
ueproductisnotworkingproperlyoryouhavesuftered
anadversereaction;and qualityofimportsand
drug
ensuring
PortingsuspiciousmedicalproductstoyourNational
MedicinesRegulatoryAuthority.
incidence
ofsub-stanandfalsifiedmedicalproductsina
2006,WHOlaunchedtheinternationalmedical
2012Anti-CounterfeitingTaskForce
(IMPACT)andin
2013,
WHO
Monitor
Systemto
launchedtheGlobal
Surveillanceand
encouragecountriestoreport
structu
accuratdhdsystematicformat,tohelpdevelopamore
ate
andvalidatedassessmentoftheproblem. References
easures
forcombatingunterfeitmedicinessofarhave
uded:actionstalkenbydrugregulatory
authoritiesand
Operation
initiativesbetweendifferentlaw
enforcement
1.WHO(2005),Tech.Rep.Ser.No.933,TheSelectionandUseof
EssentialMedicines.
ovt.ofIndia(2015),NationalListofEssentialMedicines,2015.2
3.WHO(2006),FactSheetM,275,CounterfeitMedicines.
4.WHO(2018),FactSheet,Sub-standardandfalsifiedMedicalI
Products,31stJan.2018,
agencies:
providing
simple,
erpretableandcheap
5.
Govt.ofIndia(2019),AnnualReport2018-19,MinistryofHealth
patientsOrfakeand
sub-standarddrugs;and
educating
entsandhealthcareworkers.
urveillanauthenticity;
coordinatinginternational
andFamilyWelfare,NewDelhi.

126. SUSTAINABLEDEVELOPMENT GOALS
facilities,increasingtheavailabilityof
"Arson
antibiotics,aswelascontinuousimprove
Eachyearabout1.25millionpeoplediefromroadtraffic
injuriesandanother20-50millionpeoplesustainnon-latal
injuriesasaresultofroadirafficcollisionsorcrashes.Road
trafficinjuriesareamongthetop10causesofdeaths
globallyandtheleadingcauseofdeathforpeopleinl5-29
yearsagegroup.Homicideandcollectiveviolenceaccounts
foraround10percentofglobalinjuryrelateddeaths.Four
fifthsofhomicidevictimsaremenand60percentofvictims
areof15-44yearsagegroup(1).
ssgroup
surveillancecapacities.EstablishingAMR
surveillance
Of
systemswillalsobuilkdcountry
capacity
respondlorisksiromemergingpathogens.Or
and
SDG6.2.2(b)
:Proportionotpopulation
usingahand.
monitor
washingfacilitywithsoapandwater.
GPW13indicators
wild
-Numberofcasesopoliomyelitis
causedby
AproposedindicatorforSDGtarget16.1isconflictdeath
perlacpopulation.In2015,itisprovisionallyestimatedthat
1,52,000peoplewerekilledinwarsandconflicts,
correspondingtoabout0.3percentofglobaldeaths(2)
poliovirus.
Age-standardizedprevalenceolraisedblood
amongpersonsaged18+years(defined
systolic
bloodpressureof140mmigand/ordiastolichlo
pressure>90mmHg)andmeansystolicblood
pressuro
Prevalenceofobesity.
Newindicators(3)
NewindicatorsforSDGshavebeenaddedintheyear
2020.Theyareasfollows:
Healthsystem
SDG2.2.3In2016,theglobalprevalenceofanaemia
amongwomenofreproductiveagewas32.8percent
(comparedwith30.3percentin2012).Appliedtothe
latestUNpopulationestimates,thatequatedto615.8
Healthsystemstrengtheningisacorefocusofthe
SDGs
Thisisreflectedbythetactthatuniversalhealthcare(UHC
iscentraltotheoverallhealthgoalasset
out
inSDG
declarationandisassSIgnedaspecialtarget(3.8).In
orderto
movetowardstheUHCgoal,countryhealthsystemneedsto
bestrengthenedaswellasadaptedtomeettheshifting
healthPrioritiesassociatedwithdemographicand
epidemiologicaltransition,rapidllydevelopingtechnologies
andchangingpublicexpectations.lable8showsthetargets
andindicatorslinkedtohealthsystem.
millionwomenwithanaemia.Theratesofanaemiawere
highestintheWHOSouth-EastAsia(45.8percent
EasternMediterranean(39.8percent)andAfrican(39.00
percent)regions.
SDG3.6.1:Humanpapillomavirus(HPV)isthe
most
commonviralintectionofthereproductivetract,and
cancausecervicalcancer.Thevaccinetargettingg
9-14years-oldgirlsisnowofferedin90countries,butis
yettoreachthepoorestcountrieswheretherisk
of
cervicalcanceristhegreatest.Globalcoverageforafull
courseofHPVvaccinesincreasedfrom3percentin
2010to12percentin2018.
SDG3.b.3:Basedonasampleof25countries,
surveyedbetween2008and2019,onanaverageonly
22.4percentofhealthfacilitiesprovidedanavailable
andaffordable(accessible)coresetofrelevantessential
medicinesfortreatment,preventionandmanagemento
acuteandchronic,communicableandnon
communicablediseasesinprimaryhealthcaresettings.
Alotofvariationinaccesstomedicinesisobserved
betweenthese25countries.Specifically,in28percent
ofcountriesnoneofthefacilitiesprovidedaccessible
TABLE8
SelectedSDGtargetsandproposedindicatorslinkedto
healthsystems,bytypeotindicator
SDGProposedindicator
lype
indicatortarget
or
Coverage/l3.8UHCindex:tracerindicatorsonservice
access(hospitalaccess,healthworkforce
densitybyspeciticcadres,
accessto
medicinesandvaccines,IHRcapacitiesj
financial
protection
UHC:financialprotection(catastrophicand
impoverishingout-of-pockethealth
spendingS
3.8
System3.6Accesstomedicinesandvaccines
ResearchanddevelopmentonhealthissueS
thatprimarilyaffectdevelopingcountries,
includingofficialdevelopmentassistanoe(UR
Healthworkforcedensityanddistribution
IHRcapacityandhealthemergency
preparedness
17.18Datadisaggregation
17.19Coverageofbirthanddeathregistration,
completionotregularpopulation
census.
3.b
medicines.
3.c
SDG3.d.2
Byrenderingmedicinesineffective,
antimicrobialresistanceunderminesthetreatmentof
Common infectionsandincreasestheriskofspreadto
others.AfterthelaunchoftheGlobalAntimicrobial
ResistanceSurveillanceSystem(GLASS)in2016,asof
21stApril2020,atotalof91countriesandterritories
havebeensupportedtoenrollintothesystemand
participateintheannualdatacallonantimicrobial
resistanceandconsumption.Dataontheoverall
prevalenceofantimicrobial-resistancepathogensare
but
3.d
Source:(2)
ACcesstoatfordablemedicinesandvaccines
sustainablebasis
isanindicatortoSDGtarget3.b
wn
Ocussesonsupportforresearchanddevelopment
and
theatfordabilityofmedicinesandvaccmeS
limited, completeness and
currently
representativenesofthedatahavecontinuously
increasedateveryGLASSdatacall.Thelastdatacall
runin2019gatheredfrequencyofantimicrobialresistant
pathogensincommonacutebacterialinfections,
includingbloodstreaminfectionsfrom66countriesand
territories.MonitoringAMRwillhelpinformcontrol
strategiesandactionstomitigateimpactonthe
populationsuchasintormingthetreatmentprotocols,
enhancingInfectionPreventionandControl(IPC)and
water,sanitationandhygiene(WASH)inhealthcare
Communicablediseasesandnon-communicabe
thatprimarilyaffectdevelopingcountries.
AS
indicatorunderSDGtarget3.baimstocapturetheieve
researchanddevelopmentinvestments.
Solel
ThetransitionfromMDGstoSDGscannotbe
see
a
longe
asexchangeofashortlistofgoalsand
targetslor
one.TheSDGsarefundamentallydifferenttotne
MDGs,
ncC
*
isthepoliticalcontextinwhichtheyhave
eDGs
had
andasinwhichtheywillbeimplemented.ThePi

127. SOSTAINABILE
DEVELOPMENT GOALS 559
ad
moreorlessSingularpurpose.Theywere
istentaievementofimprovedhumandevelopment
marilyintermsotpoverty,educationand
developingcountries.heywereclosely
withaid-spending.heSDGsinthewords
of
ateuare"integratedandindivisible,globalinnat
aclaratoalluapplicable".Itisrelevanttoallcountriesand
omy,olderpeople,children,personswithdisabilities,
nous
people,migrantsandrefugees
-riKbeing
vennarder.Alarge-scalemultilateral
responseisneeded
to
Cnsurethatdevelopingcountrieshave
resourcestheyneed
toprotecthouseholdandbusinesses(
nt
oulcome
Realn
as$OCiated
about.
nd
universal
applicable".Itisr
IndiaandSustainableDevelopmentGoals(6)
bout
developingcountries.
hile
tuMDGswereaboutlimitedsetofhuman
evelopntalandsocialpillarsotsustainabledevelopment
AstheMDGsreachedtheirDecember2015
deadline,the
set
otSustainableDevelopmentGoals
weredeing
adaptedbyIndiaalso.Thereisnowaremarkaoie
Vergence
ofvisionunderlyingtheprioritiestortne
proposedSDGsandthoseofthenewgovernment
DuildingontheMDGs,theSDGsproposetoendpoVerty
anddeprivationinallforms,leavingnoonebehind,wnil
makingdevelopment
enironmentallysustainable.ThegovernmentotIndianas
alsoadoptedtheprincipleofSabkaSathSabkavikas
tOgether
withall,developmentforall"),withpledgethar
neirstclaimondevelopmentbelongtothepoor.ne
governmentiscallingforimprovedsanitation,healtn
education,financialinclusion,securityanddignityforall,
especiallywomen.Thepriorityisimprovingenvironmenta
aevelopmentwithrespecttowater,air,soilandbiosphere
by
treatingchallengesofclimatechangeadaptation
asan
opportunityratherthanaproblem.
menttargets,the
SDGscover
theeconomic
strong
tocusonuity;expressedmorefrequentlyit
vironmer
ith
India.
anhrase"noonewillbeleftbehind".
oralhealthtargetstolloWonfromtheunfinishedMDG
da
andmanyarederivediromWorldHealthAssembly
n5olutionsandrelatedActionPlans(1).
and
economically,
Socially
GustainabledevelopmentgoalsandCOVID-19
ReforetheCOVID-19pandemic,theprogressinthe
ement
ofSDGremainedunevenandwerenoton
rk
tomeetthegoalsbyzU50.Somegains
werevisible:
the
share
ofchildrenanayoutnOutofschoolhadfallen;the
incidenceotmanycOmmunicaolediseaseswasindecline:
accesstosafelymanageddrinkingwaterhadimproved;and
wOmen'srepresentationinleadershiproleswasincreasing.
Atthesametime,thenumberopeoplesutferingfromfood
insecuritywasontherise,thenaturalenvironment
continuedtodeteriorateatanalarmingrate,anddramatic
levelsofinequalitypersisted
inallregions.Changewasstill
nothappeningatthespeedorscalerequired.
Now,duetoCOVID-19,anunprecedentedhealth,
economicandsocialcrisisisthreateninglivesand
livelihoods,makingtheachievementofGoalsevenmore
challenging.Thedeathtollcontinuestoclimb,withalmost
nocountryspared.Healthsystemsinmanycountrieshave
beendriventothebrinkofcollapse.Thelivelihoodofhalf
theglobalwork-forcehasbeenseverelyaffected.Morethan
l.6billionstudentsareoutofschool,andtensofmillionsof
peoplearebeingpushedbackintoextremepovertyand
hunger,
erasingthemodestprogressmadeinrecentyears.
t
couldreversetheprogressinreducingmaternalandchild
deaths,COVID-19hasdisrruptedchildhoodimmunization
efortsgloballywithpotentiallydeadlyconsequences.1he
Cal
caretorthepeoplewithnon-communicablediseases
aected
asmanypeoplearenotreceivingthehealth
VICesandmedicinestheyneed.Sameisthecaseof
communicablediseasesliketuberculosis,malariaandHiv.
ndia
canprogresstowardssustainabledevelopmentin
health
ifhealthishighonthenationalandstateagenda.
his
requireshighpoliticalcommittment.Indiashouldinvest
inpublichealthandfinishagendathroughfurther
improvementinmaternalandchildhealth,confronting
neglectedtropicaldiseases,eliminatingmalaria,AIDSand
hepatitisandincreasingthefightagainstTB.Forallthese
Chalenges.theprogrammesandinterventionsneedtogivve
qualityservices,withimplementationotuniversalhealth
care.Indianeedstobuildrobusthealthsysteminallaspects
andstrengthenboththeurbanandruralcomponents,With
primaryhealthcareatitscentre.Moreinvolvementof
privatehealthsectorisvital.Indianeedstodevelopastrong
systemformonitoring,evaluationandaccountability.
Thegoalofsustainabledevelopmentcannotbeachieved
globallywithoutIndia,andtheworldwillbewatchinghow
Indiawillimplementitsnewstrategicdirectives.
References
1.WHO(2015),Healthin2015
from
MDGs(MillenniumDevelopment
Goals)toSDGs(SustainableDevelopmentGoals).
2.WHO(2016),WorldHealthStatistics,2016,MonitoringHealthforthe
Althoughthenovelcoronavirusaffectseverypersonand
omnunity,itdoesnotdosoequally.Instead,ithasexposed
uexacerbatedexistinginequalitiesandinjusticen
ancedeconomies,fatalityrateshavebeenhighest
ngmarginalizedgroups.Indevelopingcountries,the
Vunerable
-includingthoseemployedintheintorma
SDGs.
3.WHO(2020),WorldHealthStatistics,2020,MonitoringHealthforthe
SDGs.
4.UNICEF(2019),StateofWorld'sChildren,2019..
5.UnitedNations(2020),TheSustainableDevelopmentGoals
Report-2020.
6.UN-India(2015),IndiaandtheMDGs:TowardsaSustainableFuture
JorAll.
:

128. 561
WORLD
POPULATIONTRENDS
TABLE3
U.S.A
331
Birthanddeathratesinselected
developedand
developing
countriesinmid2020
India
1400.2
Deathrate
Country
Birthrate
India
20
mdonesia
271
Bangladesh
21
Pakistan
28
SriLanka
15
Thailand
10
18
Myanmar
Nepal
21
China
1439 China
10
11
7
Pakistan
220
Japan
Singapore
9
9
UK
11
Brazil
212
USA
12
Source:(2)
Theworld'sbirthratefellbelow30forthefirsttime
around1975andhaddeclinedtoabout18.2during
mid-2019(3).Inmostoftheworldthedecline
reflected
fallingbirthratesandaglobaltrendtowardssmaller
families.The
outstanding
examplesareSingaporeand
Thailand.InSingapore,in50years,thebirthratefellfrom
23perthousandin1970to9in2020;and,inThailandtrom
37perthousandto10duringthesameperiod.
Nigeria
206
Bangladesh
169
Russia
Mexico
145 128
Populationin
millioon
FIG.
1
TABLE4
Tenmostpopulated
countriesoftheworld(mid-2020)
Reductioninthebirthanddeathratesin
selected
countries,
1990-mid-2020
Source:(2)
thirdintheworldafterIndia,thereisayawninggapof
1049millionbetweenthepopulationofthesetwocountries.
TheUnitedNationshasestimatedthatworld'spopulationis
growingatanannualrateof
l1.1percentintheyear2019.
ThreecountriesofSEAR,i.e.India(1400
million),
Indonesia(271million),and
Bangladesh(169million)are
amongthemostpopuloustencountriesoftheworld.At
presentIndia'spopulationissecondtothatofChina.
AccordingtoUNprojectionsIndia's
population
willreach1.53
billionbytheyear2050,and
willbethehighestpopulation
countryintheworld.Thetrendofpopulation
increasein
SouthEastAsiaRegioncountriesisasshowninTable2.
Deathrate
Birthrate
Country 2020 1990
mid-2020
1990
21
10
5
35Bangladesh
Nepal
38
21
13
20
11
6
India
31
15
7
6
SriLanka
21
19
10
8
Thailand
18
9
Singapore
7
23
10
China
6
28
11
Pakistan
40
Source(2)
Inallthesecountries,keyfactorsinfertilitydecline
includedchangesin
governmentattitudestowardsgrowth,
TABLE2
rends
inincreaseofpopulationofSEARcountries
(inmillion)
increased
availabilityof
the
spreadof
education,
contraceptionandtheextensionofservicesofferedthrough
familyplanning
programmes,aswellasthemarkedchange
inmarriage
patterns.1991
mid-2020
Country
Deathrateshavealsodeclined
worldwideoverthelas
decades.Theglobaldeathratedeclinedfrom11.0(betweer
1975-1980)to7perthousand
populationduring2018,
reductionof23percent.Thedeclineinthedeathrateof
the
South-EastAsiaRegionhasbeenmoremarked,from14.
to7.0per1000
population.
Incountrieswitharelative
youngpopulation,crud
deathratesaremainlyattectedbyintfantandchildmortalit
With
improvementinmaternalandchildhealthservice
successful
implementationofthe
expanded
programme
immunization,diarrhoealdiseaseandacuterespirato
infectioncontrol
programmes,aswellaswiththecontrol
other
infectiousdiseases,therehasbeenmarkedreducti
ininfantandchildmortalityrates,whicharereflectedin
1
decliningcrudedeathrates.
843.9
1,400.0
India 169.8
118
Bangladesh 0.7
1.5
Bhutan 271.7
187.7
Indonesia 0.5
Maldives
0.221
54.7
42.5
Myanmar 30.0
19.6
Nepal 21.9
SriLanka
17.4
66.5
Thailand
56.4
Source
(2,3)
Birthanddeathrates
Countdring
contrastsinbirthand
death
ratesin
selected
ountriesare
asshowninTable3.

129. each
cadehasbeenontheincreasesince1921(Table6).
60
ye.ars
439million(1961);doubledagain,thistimein
563DEMOGRAPHIC TRENDSININDIA
onhasbeensteadilyincreasing
sinceIndia's
1921iscalledthe"bigdivide"becausethe
centtothenation-wideincreaseinpopulation.
Demographic
Ourcomesinthesestateswilldeterminethetimingand
s1zeof
PopulationatwhichIndiaachievespopulationstabilization.
1921.The
year
olutenumberorpeopleaddedtothepopulationduring
increasingattherateof
populationiscurrently
AgeandsexcompositionIndia's
lion
each
year.
a'sDopulationnumbered238millionin1901,doubled
only
1bilion
1.53
billion
most
Withthe
division
30
yearstoreach846millionby1991.Itcrossed
bytheyear2050ThiswillthenmakeIndiathe
populouscountryintheworld,surpassingChina.
heage-sexcompositionofIndia'spopulationisas
showninTable8.Intheagegroup0-14yearsmale
populationisabout1.2percentmorethanfemale,whereas
the
agegroup60+,percentageoffemalepopulationis
0.
percentmorethanmalepopulation.Theproportion
or
Populationintheagegroup0-14yearsishigherinrural
areas(2/.5percent)thaninurbanareas(22.6percent),1or
bothmaleandfemalepopulation(7).
1arkon1lMay2000,andisprojectedtoreach
of
somestatestherankofmostpopulous
Table7showsthetenmostpopulous Theproportionofpopulationbelow14yearsofageis
showingdecline,whereastheproportionofelderlyinthe
countryisincreasing.Thistrendistocontinueinthetimeto
Come.Theincreaseintheelderlypopulationwillimposea
greaterburdenonthealreadyoutstretchedhealthservicesin
thecountry.
changed.
stateshave
statesin
the
o$Cond
with128.711millionpeopleandBiharcomes
Kiwith108.377millionpeople.Thesetenstatesaccount
fnr
about
71percentofthetotalpopulationofIndia(7).
countrybyrank.ItisseenthatUttarPradesh
firstwithabout231.425millionpeople,Maharashtra
TABLE7 TABLE8
Rankingofmostpopulousstates
byprojectedpopulationsize2020
Percentdistributionofestimatedpopulation
byageandsex.India(2018)
Populationpercentage
Population
2020
Percenttototal Age
group FemalespopulationofIndia
2020
RankState Total Males
(000)
7.88.0 8.2
8.6,
Lwjte8.8
9.5
0-4
231,425
128,711
1 UttarPradesh 16.7
5-9 8.4
2
Maharashtra 9.0 10-14 9.3 9.1
7.8108,377
90,949
82,134
76,759
70,617
65,532
64,410
43,732
Bihar 10.4 10.010.2
10.8
. 15-19
4.AndhraPradesh 6.5 20-24 10.5 11.0
MadhyaPradesh
Rajasthan
TamilNadu
5.9 25-29 10.1i7 9.9 10.2.
5.5 8.4
7.3
6.2
8.58.4
7.3
30-34
5.0 35-39 7.2
4.7 6.2Gujarat
Karnataka
8. 40-44 6.2
4.6 5.345-49
50-54
9. 5.3 5.3
10.Odisha 3.1 4.2 4.3 4.2
3.4
1 2.9
55-59 3.5 3.6
Source:(8)
60-64 3.0 3.0
Ithasbeenestimatedthatwithcurrenttrends,the
populationinIndiawillincreasefrom1.210billionto
1.4billionduringtheperiod2011to2026.Thereisa
Substantialdifferenceintotalfertilityrateinbetweenandwithin
states.AtoneendofspectrumaresouthernstateslikeKerala,
lamilNadu,KarnatakaandAndhraPradeshwithtotalfertility
rateatorbelowreplacementlevels.Attheotherendarehigh
ertlitystateslikeUttarPradesh,Chhattisgarh,Uttarakhand,
Hajasthan,
Jharkhand,Bihar,MadhyaPradeshandOrissa,
wIthanestimatedtotalfertilityrateofmorethan2.2.
IheGovernmentofIndiahascategorizedstates
cordingtototalfertilityrate(TFR)levelintoveryhigh-
usmorethanorequalto3.0),high-focus(morethan2.
ess
than3.0)andnon-highfocus(lessthanorequal
Categories.Thestatescategorizedasveryhigh-focus
andhighfocusareasfollows(9
TFR
2.2-3.0
2.1 2.165-
70--74
2.2
1.4 1.3 1.5
75-7 0.9 0.8 0.9
0.5sr( 0.4
0.3
80-84 0.5
85+ 0.2 0.3
Total 100.0 100.0 100.0
Note:Totalmaynotaddupto100duetoroundingoff.
Source:(7)
Populationpyramid
Populationpyramidisalsoknownas"AgeandSex"
pyramid.Itisagraphicalrepresentationoftheageandsexofa
population.Itshowsthedistributionofagesacrossa
populationdivideddownthecenterbetweenmaleandfemale
membersofthepopulation.Thegraphicstartsfromthe
youngestatthebottomtooldestatthetop.Itiscalledapyramid
becausewhenapopulationisgrowing(therearemorebabies
beingbornthentherearepeopledying)thegraphicformsthe
shapeofatriangle.Apopulationpyramidcanbeusedto
comparedifferencebetweenmaleandfemalepopulationofan
area.Theyalsoshowthenumberofdependentsandgeneral
structureofthepopulationatanygiventime(10).
Fig.2showsageandsexpyramidofIndiaand
Switzerland.Thepyramidistypicalofdevelopingcountries,
withabroadbaseandataperingtop.
Assam-2.3,Dadra&Nagar
Haveli-2.3,Mizoram-2.3,
Chhattisgarh-2.5,Jharkhand-2.6,
Manipur-2.6,Rajasthan-2.7,
Nagaland-2.7,MadhyaPradesh-2.8
Bihar-3.3,UttarPradesh-3.1and
Meghalaya-3.0
TFR
more
than
Or
equal
to3.0
tismatter
ofconcernthatthesestateswilldelaythe
attainr
highferssotreplacementleveloffertilityinIndia.These
atesareanticipatedtocontributeabout50per

130. SWITZERLAND
Population8.65million(mid-2020)
564
DEMOGRAPHY AND
FAMILYPLANNING
INDIA
Population1390million(end-2020)
100
95-99
Male FemaleD0
Female
Male
90-94
on.s4
85-89
S0-84
0-74
65-69
0-74
60-64
5-6
5-59
60-64
S9-54
55-59
S0-54
43-4
4044
353936.39
-34
25-29
30-34
0-24
25.29
4
15-19
15-19
10-14
4 6
6%
FIG.2
PercentagedistributionbyogeofthepopulationofIndiaandofthepopulationofSwitzerland.
Sexroliootbirth:Sexratioatbirthcanbealfectedby
sex-selectivityatbirth.ThesextatioatbirthforIndiaforthe
year2016-2018hasbeenestimatedat899.
It
varies
from
900inuralareasto897inurbanareas.Amongthebigger
stales,1hesexratioatbirthvariesfrom958inChhattisgarh
840in1laryana.Intheruralarcas,thehighestandlowest
sextatioatbirthareinthestalesofChhattisgarh(976)and
Haryana(840)respectively.Thesexratioinurbanareas
Sexratio
Sexratioisdefinedas"thenumberoffemalesper1000
males.Oneofthebasicdemographiccharacteristicsof1he
populationisthesexcomposition,Inanystudyof
populafion,analysisofthesexcompositionplaysavilal
role.Thesexcomposílionofthepopuiafionisaffectedby
thedifferentialsinmortalityconditionsofmalesand
females,sexselectivemigrationandscxralioatbirh.
"Femaledeficitsyndrome"ísconsideredadversebecauseof
$ocialimplications.Alowsextatioindicalesstrongmale-
childpreterenceandconsequentgendeinequilics,neglect
ofthegirlchildresultinginhighermorlalityatyoungerage,
femaleinfanticide,femalefoeticide.highermaternal
mortalityandmalebiasinenumerationofpopulalion.EAsy
availabilityofthesexdeterminatíonfestsandabortion
servicesmayalsobeprovingtobecatalystintheprocess,
whichmaybefurtherstimulaiedbypreconceptionsex
selection1acilities.
variesfrom968inMadhyaPradeshto810inUttarakhand.
Table10showstlhevariationsofsexratioatbirthby
residenceinthebiggerstatesofthecountry.
TABLE10
Sex1atioatbirthbyresidenceinIndia120162018)
No.ofFemalesper1000males
Total Rural
Biggerstetes
Urban
898
905
883
930AndhraPradesh
Assam
920
927
Thetrendsinthesexratiointhecountryirom1901
onwardsareasshowninTable9.
925
Bihar
895 896
976
881Chhattisgarh
Delhi
TABLE9
958
844 960 841
CXTati0Inna1a
865
Gujarat
Haryana
HimachalPradesh
Jammu&Kashmir
866 866YCar Femalesper1000males
840
847
932
891
1901
1911
927 930 917
4
888
881
Jharkhandd
Karnataka
Kerala
MadhyaPradesh
Maharashtra
Odisha
1921
955
923 932
950
945
949
967
924
1931
1941
1951 957 947
946
925 914 968
941
880 878
881
1971
930
933 940
891
Punjab
Rajasthan
TamilNadu
908
860
981
934
890 878
1991
927
871 8742001
2011
933
903
908 913
875
934
Telangana
OttarPradesh
Uttarakhand
WestBengal
918
865
901Source
880
810
840 851
Thesex
ratioinIndiahasbeengenerallyadversetowomen,
i.e.,thenumberofwomenper1,000menhasgeneralybeenlessthan1,000.Apartfrombeingadversetowomen,
thesexratiohasalsodeclinedoverthedecades.
923
941 947
ind
899 900
897
Source:(7)

131. URBANIZATION 565
Census2011marksaChild
erable
considhasreachedanalltimelowo1914since1961.
Thea
yeas
has
been
13pointsirom9271o914forthecountry
sexratio(0-6years)
advantage
istakenofthedemographictransitionwithhigh
economicgrowthrates(13).
fallinchildsexratiointheagegroupof0-6
2001to2011.InTuralareas,thefallhasbeen
dutant-15pointsirom93410919andinurbanareasit
Sen4pointsfrom9ubto902overthedecade(6).
heterm"demographicburden"isusedtoconnotethe
ncreaseinthetotaldependencyratioduringanyperiodot
tme,mostlycausedbyincreasedoldagedependencyrati0.
his
isaninevitableconsequenceofdemographic
transition,
andthecountryhastofacethisproblemsooner
oor
later(13).
a5
Dependencyratio
The
proportionofpersonsabove65yearsofageand
childrenbelowo
yearsoageareconsideredtobe
Aonendantonheeconomicallyproductiveagegroup
(15-64years).Theratioofthecombinedagegroups0-14
OATS
plus65yearsand
above
101he15-65yearsagegroup
Teferredtoas
thetotaldependencyratio.
It
isalsoreferred
1oasthesocietaldependencyratioandreflectstheneed
forasociety1oprovide1ortheiryoungerandolder
populationgroups.
i
hedependencytatiocanbesubdivided
intoyounsagedependencyTatio(0-14years);andold
agedependencyratio(65yearsandmore).Theseratios
are,however,relatively
crude,sincetheydonot1akeinto
considerationelderlyoryoungpersons
whoareemployed
orworkingagepersonswhoareunempioyed,
I1
isgivenby
thetormula:
Densityofpopulation
Oneoftheimportantindicesofpopulationconcentration
1S
thedensityofpopulation.
Itistheratiobetween(total)
populationandsurface(land)area.Thisratiocanbe
calculatedforanyterritorialunitforanypointin
ume,
dependingonthesourceofthepopulationdata(13).Inthe
indiancensus,densityisdefinedasthenumberofpersOns,
livingpersquarekilometre.Thetrendsofthedensityinthe
countryfrom1901onwardsareasshowninTable11.For
theyear2020thedensityofpopulationpersq.km.in
Indiawas464.
TABLE11
Densityofpopulationinhdia1901-2011
Children0-14yearsage
+ Year Persq.km
Total
Populationmorethan65yeatsofage
x100
Populationof15to64years
1901 77
dependency
tatio 1911 82
1921 81
ForIndia,1hedependencyratiofortheyearmid-2020is
calculatedas:
1931 90
1941 103
%ofpopulationin0-14yearsagegroup
-26.2percent
1951 117
%ofpopulationabove65yearsofage
%ofpopulationin15-64yearsagegroup-67.3percent
6.6percent 1961 142
1971 177
1981 216
Total
26.2+.0x1000
1991 267
dependency
ratio 67.3
2001 325
2011 382
t48.736percent
Source:(0)
he
youngagedependencyratiois26.2percent,
andoldagedependencyratiois6.6percentfortheyear
mid2020(12).
Urbanization
Forinternationalcomparison,thechild,oldandtotal
pendencyratiosareusedtostudy1hedependencyburden
the
population.Thetotaldependencyratiotends1o
creaseintheearlierstagesofdevelopmentwhenrapid
cine
infertilityreducesthechildpopulationmorethan
neincreaseintheolderpersons,butsubsequenuyhaving5,000ormoreinhabitants,adensityofnotlessthan
ase
inolderpersonsfarout-weighsthedeclineinthe
population.Thereisashiftfromchilddependency
10
ihgedependency,asfertilitydeclinesandlifeexpectancy
Bydefinition,urbanpopulationisthenumberofpersons
residinginurbanlocalities.Thedelinitionofurbanlocality
variesfromcountrytocountry.InIndiancontext,theurban
areasarethe"Tons(placeswithmunicipalcorporation,
municipalareacommittee,towncommittee,notified
areacommitteeorcantonmentboard);als0,allplaces
1,000personspersquaremileor390persquarekilometre,
pronouncedurbancharacteristicsandatleastthreefourths
oftheadultmalepopulationemployedinpursuitsother
thanagriculture"(13).
incteases.
child
The
d declineindependencyratios,especiallythe
Thepopulationinlndiacontinuestobepredominantly
ruralwithagricultureasthemainoccupationforthe-
najorityofthepeople.
Asperpopulationtotalsfortheyear2019,theurban.
opulationstandsat471.828million(34.5percent)
Mumbaiisthehighestpopulouscitywith12.69millior
followedbyDelhi10.927million,BengalurucomesthirC
with5.104million,Kolkata4.631millionisfourthane
Chennai(4.328million)istith.Fig.3indicatesthelevelo
urbanizationinthecountry(11).
underthaencyratio,hasbeenidentifiedtobeakeyiactor
democrpaeconomicdevelopment.he
term
Qemographic
bonusdepend
connotestheperiodwhenthe
nfo cyratioinapopulationdeclinesbecauseofdecline
lonoeuntilitstartstoriseagainbecauseofincreasing
ertilins
perioddependsonthepaceofdeclinein
ast,tho Olapopulation.Iftheswitchtosmall1amiliesis
deveemographicbonuscangiveaconsiderablepush
t10
Skde
investmentinhealthcareandeducationfor
velopnaremadeduringthisperiod,maximum

132. 15andlivingtill45withherhusbandisexposedtothe
ofpregnancyfor30years,and
maygivebirth
15children,butthismaximumisrarelyachieved.
Fertilitydependsuponseveralfactors.Thehigherfertilie
inIndiaisattributedtouniversalityofmarriage,lowerad
marriage,lowlevelofliteracy,poorlevelofliving,
limitod
useofcontraceptivesandtradifionalwaysoflife.Natian:
FamilyHealthSurvey-4ConductedinIndia
uring
568
DEMOGRAPHY ANDFAMILY
PLANNINNG
sk
Lite
expectancyatbirthhascontinuedtoincrease
globallyovertheyears.For1950-1955,the
combinedlite
expectancyatbirthforbothsexeswas46.5years.Five
decadeslaterby2008,itwas69yearsanincreaseof22.5
years.Theincreasehasbeenmoremarkedinlessdeveloped
regionsoftheworldthaninthedevelopedregions(15).
to
m
Mostcountriesintheworldexhibitasex
differentialin
mortalityfavouringwomen
-femaleslivelongerthanmales
asshowninTable14and15.
2015-2016provides
somedetailedinformationoffertilit
trends,asshowninTable16.
Trendsinlifeexpectancyshowthatpeopleareliving
longer,andtheyhavearighttoalonglifeingoodhealth,
ratherthanoneofpainanddisability.Healthpolicymakers
thusneedtorecognizethischangingdemographicpattern
andplanforpreventionandcontrolofdiseasesassociated
witholdage.
TABLE16
Totalfertilityratebyselectedbackgroundcharacteristics
(2015-16)
NationalFamilyHealthSurvey-4
Totalfertilityrate
Background
characteristics
Tables14and15presentlifeexpectancyatbirthinIndia
andthoseinselectedcountries.Japanleadsinlife
expectancyforbothmalesandfemales,81and87years
respectivelyfortheyear2020.
Residence
1.75
Urban
2.41
Rural
Education
3.06
2.43
2.38
TABLE14
Noeducation
<5yearscomplete
5-7yearscomplete
8-9yearscomplete
10-11yearscomplete
12ormoreyearscomplete
Expectationoflifeatbirth,yearsinIndia
Year Males
FemalesS
2.19
1.99
1901 23.63 23.96ce
1.71
1911 22.59 23.31
Religion
Hindu
1921 19.42 20.91
2.13
1931 26.91 26.56
2.61
Muslim
1941 32.09 31.37 1.99
Christian
1951 32.45 31.66 Sikh
1.58
1961 41.89 40.55 Buddhist/Neo-Buddhist
1.74
Jain
1.20
1971 46.40 44.70
Other
2.57
1981 54.10 54.70
Caste/tribe
1991 59.70 60.90
2.26
Scheduledcaste
2001 63.90 66.90 2.48
Scheduledtribe
2011 64.00 67.00
Otherbackwardclass
2.22
Others
1.93
Source:(6)
Don'tknow
2.81
Wealthindex
TABLE15
3.1
2.45
Lowest
Expectationoflifeatbirth,years,inselectedcountries2020 Second
Developing 2020
Middle 2.07
Developed
MaleFemalecountries
2020
countries
Fourth 1.84
MaleFemale
Highest 1.54
Nepal 67 70 UK 79 83
Total 2.18
Bangladesh71 74 USA 76 81
Myanmar 64 69Sweden 81 85 Source:(18)
India 68 70Switzerland 82 85
Someofthefactorswhichhaveengagedattentio
demographerssincelongarediscussedbelow.
SriLanka 74 80RussianFederation68 78
Thailand
Pakistan
73 80Japan 81 87
67 71Singapore 1.Ageatmarriage
81 85
Theageatwhichafemalemarriesand
enters
fertility
the
Source(2)
reproductiveperiodoflifehasagreatimpactOituon
a
TheRegistrarGeneralofIndiacollected
nationalscaleandfoundthatfemaleswhomarry
ore
theFERTILITY dataon
fertilit
ageof18gavebirthtoalargernumberof
children
thosewhomarriedafter(19).InIndiasomedemon
rapher
haveestimatedthatifmarriageswerepostponed
ageof16to20-21,thenumberofbirthswouldde
20-30percent(19).
than
Byfertilityismeanttheactualbearingofchildren.Some
demographersprefertousethewordnatalityinplaceof
fertility.Awoman'sreproductiveperiodisroughlyfrom
15to45yearsaperiodof30years.Awomanmarriedat
from
ecreaseby

133. 571FERTHLITYRELATEDSTATISTICS
Birthanddeathrates
TFR CBR
Thebirthanddeathratesareimportant
componentsof
populationgrowth.ThebirthanddeathratesinIndiaare
showninTable18.AlookatTable18showsthatwhereas
thedeathratehasconsiderablydeclinedfrom274in1951
toanestimated6.2perthousandpopulationin2018,
the
birthratehasdeclinedniggardlyfrom39.9in1951toan
estimated20.0perthousandin2018.
20.0
Jndia
2.9
Uttar
Pradesn
25.6
26.2Bihar
2.5
24.0Rajasthan
2.7
Madhya
Pradesh
24.6
TheFifthFiveYear(1974-79)Plan'sobjective
wasto
reducethebirthratefrom35perthousandatthebeginningof
thePlanto30perthousandby1978-79.During1979-84,the
birthratewasstagnatingaround33perthousandwithno
obviousdecline.During1990,however,thebirthrateshowed
aslightdecline,toanestimated30.2,furtherdecliningto26.4
bytheyear1998.Thecurrentpictureindicatesthatbirthand
deathratesarebothdeclininginIndia.
20.3
Haryana
2.2
21.1
Assa
19.7
Gujarat
19 18.2
Odisha
Himachal
Pradesh
15.7
15.6Maharashtra
14.8 TABLE18
Punjab
5 Birthanddeathratesinindia
15.0West
Bergal
1.7 Birthrate
Deathrate
17.2 YearKarnataka
27.4
22.8
19.0
15.0
12.5
9.8
9.0
9.0
39.9Andhra
Pradesh
16.0
1941-1950
41.7
1951-1960
1961-1970
1.6 14.7
TamilNadu
41.2
.7
37.2
33.9
29.5
28.3
26.8
13.9
Kerala 1971-1980
2.5 22.6 1981
Jharkhand
1991
1995
1998
999
22.5
ahansgan
1.5 14.7
Delhi
26.1
25.0
24.1
23.5
22.8
8.1
8.1
1.5
7.5
1.6 15.4J&K
2002
2004
2006
2008
2010
2012
2015
2016
2018
16.9
Telangana
1.8 16.7
7.4
7.2
7.0
Utarakhand
25
30
22.1
21.6
20.0
10 15 20
FIG.5 7.0
Crudebirthrate(2018)andTotalfertilityrate(2018)
formajorstates
64
6.2
20.4
20.0
Source:(7,25)
Source:(7)
Recentestimatesofthefertilityindicatorsandage
SpeciticfertilityratesinIndiaaregiveninTable17. Indialikeotherdeveloping
HIGH
BIRTHRATE
countriesisfacedwiththedilemmaofahighbirthrateanda
decliningdeathrate.Thisisaviciouscircle,noteasyto
break.Thecausesofhighbirthrateare(1)Universalityof
marriage
Marriagesareuniversalandsacramental.
Everyone,soonerorlater(usuallysooner)getsmarriedand
participatesinreproduction.Theindividual'seconomic
securityoremotionalmaturityareseldomapre-requisiteto
marriage.
(2)Earlymarriage:Marriagesareperformed
early.Dataindicatethatabout60percentofthegirlsaged
15-19yearsarealreadymarried.(3)Earlypuberty:Indian
girlsattainpubertyearly,between12and14years.(4)Low
standard
ofliving:Wherestandardsoflivingarelow,birth
rates
arehigh.(5)Lowlevelofliteracy:The2011census
showedthatonly74.04percentofthepopulationwas
literate.Thefemaleliteracyisstilllower,especiallyinthe
ruralareas.(6)Traditionalcustomsandhabits:Customs
dictatethateverywomanmustmarryandeverymanmust
haveason.ChildrenareconsideredagiftofGodandtheir
birthshouldnotbeobstructed.(7)Absenceoffamily
planninghabit:
Familyplanningisofrecentorigin.
Ithasnotyetbecomepartofthemaritalmoresofthepeople.
DECLININGDEATHRATE:Thedecliningdeathratehas
been
attributedto(1)
absenceofnaturalchecks,e.g..
faminesandlargescaleepidemics,(2)masscontrolof
TABLE17
FertilityindicatorsofIndia,2018
TotalRuralUrban
Indicators
Agegroup
12.213.5 8.4
Age-specificfertilityrate 15-19
91.5
122.9135.9
146.4
160.1
119.1
101.3
40.7
14.8
5.5
20-24
-29
30-34
35-39
4044
45-49
94.7
36.9
81.
30.2
9.1
2.4
12.7
4.4
15-19
20-24
25-29
322.7
332.4
299.8
309.0
190.9
199.0
289.7
273.6
173.2
92.6
32.7
9.9
Age-specificmarital
fertilityrate
30-34
103.4
109.2
35-39
39.5
4044
45-49
43.2
15.9
6.1
21.6
17.4
2.4
13.7
4.9
2.7
16.7
56.7
1.7
20.0
Crudebirthrate
Generalfertilityrate
Totalfertilityrate
Gross
reproductionrate
eneralmaritalfertilityrate
lotalmaritalfertilityrate
70.4
2.2
1.0
0.8
1.1
89.3
109.2
119.1
4.9
4.4
5.1
Source:
(7)

134. 592 DEMOGRAPHY ANDFAMILY
PLANNING
TABLE24
ModerncontraceptiveusagePercentageofcurrentlymarriedwomenwithunmetneedfor
familyplanninginlIndiabyselectedbackground
characteristics
(NFHS-4,2015-16)
Demandsatistiedbymoderncontraceptives
Andhra
radesh
relangana 56.9
Unmetneedtor
familyplanning 3.Maharashtra
62.6
Backgroundcharacteristics
834.0
ForspacingForlimitingTotal TamilNNadu 2.6
83.1
KarnatakaAge
15-19 82.519.9 2.3 22.2
Haryana 9.4
J81.4
80.9
20-24 15.7 6.5 22.3
Punjab
25-29 8.4 10.3 18.7
80.9Madhya
Pradesh
49.612.5|
8.3|
5.8
30-34 3.1 9.4
78.135-39
40-44
1.07.3
0.3
Gujarat
77.95.5
B0.3Kerala
45-45 0.1 3.3 3.4
75.3
Rajasthan
74.3
Residence
Urban
West
Bengal
5.1 7.0 12.1
72.7
Rural 5.9 7.3 13.2
Chattisgarh
2.5Schooling3
India 47.8
T2.0Noche .4 7.6 0ling
<5yearscomplete
5-7yearscomplete
8-9yearscomplete
Himachal
Pradesh 552.13.8 6.3 10.1
71.7
6.6 11.7 Utarakhand 149.35.0
11.6
7.4 14.1
46.1
6.7 Jammu
&
Kashmir 66.213.6
17.0
6.7 6.910-11yearscomplete
12ormoreyearscomplete
43.4Odisha
64.09.5 T.5
Jharkhand
63.8
Religion
Hindu 54 7.0 12.4 Assam i.0..0
Muslim 7.1 9.4 16.4
.3
Bihar
51.4Christian 6.9 6.0 12.9
Uttar
Pradesh
3L
49.8Sikh 2.4 4.0 6.4
Buddhist/Neo-Buddhist 4.9 6.2 I1.1
0102030405060708090100
Jain 4.0 8.0 12.1
9.5 18.3 FIG..8Other 8.8
ModerncontraceptiveuseandDemandsatisfiedbyit,IndiaCaste/tribe
Scheduledcaste
Scheduledtribe
5.4 6.7 12.1 Source:(9)
6.2 6.8 13.0
coverageandquality.offamilyplanningservices,
especiallyinthestatesofUttarPradesh,Bihar,Assamand
Jharkhandetc.
Otherbackwardclass 6.0 7.3 13.4
Other 5.0 7.4 12.4
Don'tknow 7.8 11.7 19.4
Wealthindex
Lowest
Second
Middle
Fourth
Highest
Contraceptionandadolescence(112)
.7 10.1 16.7
Adolescenceistheperiodbetweenpubertyandtheeu
Ophysiologicalmaturation,whichoccursbetweenag
72 13.0O.8
5.3 6.2 11.5
11.8|15-19years.Pregnancyinadolescenceconstitutesaet
5.4 6.4
11.6lpercentofallpregnanciesinmostdevelopingcoh
andinsomedevelopedcountriessuchastheUSA.ro
5.1 6.5
year2014,WHOputstheglobaladolescentbirtha5.6 7.2 12.9Total
49per1000girlsofthatage,countryratesrange
obe
toZ29birthsper1000girls.Thisindicatesa
al
Source(18)
decreasesince1990(113).Theseareoftena
risk
pregnancies.Manyareundesired,andoccurin
t
adolescentswhothenresorttolegalorillegal
ais
has
narried
periormedunderunsatisíactorymedicalcondition.c
for
"Demandsatisfied"bymoderncontraceptives
Demandsatisfied'calculatestheneedsatisfiedbymodern
methodsoutoftotaldemandinthecommunity(includesthe
cohortusingmoderncontraceptivesandtraditionalmethods,
andhavingunmetneedforcontraception).India's'demand
satisfied'showsanincreasefrom69.1percentinNFHS-IIIto
72percentinNFHS-IV.Fig.8showsthestatewise'demand
satisfiedandmoderncontraceptiveusage.12statesshow
"demandsatisfied'ofmorethan75percent.
TheNationalFamilyHealthSurvey-4resultsshowthat
althoughcurrentuseofcontraceptionhasincreased,andthe
extentofunmetneedhasdeclinedinmostofthestatesin
India,thereisaneedforconsiderableimprovementinthe
serioushealthandevenlife-threateningconsearbidity
tneseyoungwomentheensuingmortalityana
especiallysecondarysterility)arequiteconsiderao
Preventionofundesiredpregnanciesanducaliona
transmitteddiseasesinyoungpeople
throughedu
programmesdealingwithresponsiblesexua
ambivalen
viouris
a
majorpublichealthchallenge.Adolescens.arto"revea
aboutfamilyplanning
:torequestcontraceploometime
one'ssexuality.Forthisreason,adolescentgan
abortion
choosetheriskofanundesiredpregnancyando
M

135. 594 DEMOGRAPHY ANDFAMILYPLANNING
than5,000,typeBforareaswithpopulationbetween
5,000-10,000,typeCforpopulationbetween10,000-
,00.and
typeDforareaswithpopulationbetween
25,000-50,000.Ifthepopulationismorethan50,000,then
Itistobedividedintosectorsof50,000populationand
HealthPostsprovided.TypeA,BandCHealthPostsare
attachedtoahospitalforprovidingreferralandsupervisory
services.ypeDHealthPostisattachedtoahospitalfor
sterilization,MTPandreferral(32).OnlytypeDhealthpost
haveapostofmedicalofficer.
Theprogrammeofinsertionofcopper-TIUDs
has
beer
intensified.Itisintendedthatlaparoscopicserviceswhi
havebecomeverypopularwillbemademore
widely
availableatthePHC.
Thesub-centresaretoprOvIdethemainthrustoftho
programme.Eachsub-centre
isstaltedbyonemale
and
ona
femalehealthworker.Theyareresponsibleforprovidino
rudimentaryhealthandMCH care;familyplannina
motivation,suppliesandserVIcesinspacingmethods.
The10cityfamilywelfarebureausareentrustedwiththe
responsibilityofcoordination,monitoringandsupervision
etc.ofthefamilywelfareservicesprovidedbyvarious
institutionsinthecity.
Variousstudiesconductedhavehighlighted
thattho
existinginfrastructureisnotbeingoptimallyutilizedbecause
ofitsinadequacytoproviaeproperServices.loimprove
matterspopularcommtteesnavebeensetupatall
levelsbysomestatestoinvolvepeopleintheprogramme
andinexercisingvigilanceovertheworkofvarious
PresentlytherearethreetypesofUrbanFamilyWelfare
Centres.Type
I
isforpopulationbetween10,000-25,000,
type isforpopulationbetween25,000-50,000,and
typelllisforabove50,000population(32).Theseare
mannedby2para-medicalstaffintypeIandlIcentresand
by6personsincludingmedicalofficerintypeIllcentres.
functionaries.
Atthevillagelevel
Twoschemesarebeingimplementedatthevillagelevel
toimprovetheoutreachofservicesandincreaselocal
participation:(a)TheVillageHealthGuidesAn
innovativeapproachhasbeenthecreationofabandof
villageHealthGuides(mostlywomen),oneforeachvillage
orapopulationof1000.Theyaremaderesponsiblefo
spreadingknowledgeandintormationtotheeligiblecouples
andprovidingthemwithsuppliesofNirodhandoral
pills.About3.23lakhhealthguidesareinposition.
(6)Traineddais:Thenationaltargetistoprovideone
traineddaiper1000population.Theyconductsafe
deliveriesinruralareas.Theyalsoactasfamilyplanning
counsellorsandmotivators,supplementingthedelivery
system.(c)ASHA
:
9.15lakhASHAshavebeenselectedso
farandhavebeenprovidedwithdrugkits(34A).Atpresent
thevillagehealthguides,traineddaisandASHAsarethe
lynchpinsofthefamilyplanningdeliverysysteminIndia.
TheUrbanfamilywelfarecentresandhealthposts
providecomprehensiveintegratedservicesofMCHand
familyplanning.Thestaffpatternisdifferentfordifferent
typesofhealthpostsandurbanfamilywelfarecentres.
Atthecommunityhealthcentre
Communityhealthcentreisestablishedandmaintained
bythestategovernments.Presentlyitismannedbyfour
medicalspecialistsi.e.surgeon,physician,gynaecologist
andpaediatrician,supportedby21paramedicalandother
staff.Ithas30in-doorbedswithoneO1,X-ray,labour
roomandlaboratorytacilitiesandservesasareferralcentre
forfourPHCs.AccordingtoIndianPublicHealthStandards,
thecommunityhealthcentreistobemannedby6medical
specialistsincludingananaesthetistandaneyesurgeon
supportedby24paramedicalandotherstaffwithinclusion
oftwonursemidwives.t
provides,apartfromother
emergencyobstetriccare,fullrangeoffamilyplanning
servicesincludinglaproscopicservicesandsafeabortion
services.AtpresentasofMarch2018,5,624community
healthcentresarefunctionalinthecountry.
Familyplanninghasasignificantroleinmitigatingthe
impactofhighpopulationgrowthbyhelpingwomenachieve
desiredfamilysizeandavoidunintendedandmisitime
regnancies.Pastfewyearshaveseenaparadigmshittn
familyplanningprogramme.Studiesshowthatifthecurent
inmetneedforfamilyplanningcouldbefulfilledovertne
next5years,35,000maternaldeathsand1.2millionintant
deathscanbeaverted.Thefocusoftheprogrammeisno
towardsmeetingtheunmetneedofcontraception
increasingtheuseofmoderncontraceptiveuse,tnerr
neip
inavertingunintendedandmistimedpregnani
achievedesiredfamilysize,andpromotethehealtno
motherandchild.
Attheprimaryhealthcentre
Since
morethan65percentofIndia'spopulationlivesin
theruralareasanadequatenetworkofservicecentreshas
beenextendedtotheruralareas.ARuralFamilyWelfare
Centrewithamedicalofficerandsupportingstaffformsan
integralpartoftheprimaryhealthcentre.Atotalof5,435
RuralFamilyWelfareCentreswereestablishedinthecountry
atallblocklevelPHCssanctionedupto1.4.1980.Mostof
thestateshaveintegratedthesecentresintotheirprimary
healthcaresystemandafterthisdatefamilyplanning
servicesarebeingprovidedthroughintegratedfacilitiesat
PHCs.AsofMarch2018,25,743primaryhealthcentres
werefunctioninginthecountry.Eachcentreissupportedby
Sub-centres.Thetotalnumberofsub-centresfunctioningare
1,58,417
Whenfullystaffed(by3medicalofficersincludingone
ladydoctorandsupportingpersonnel)thePHCisexpected
toprovidefairlycomprehensive"essentialhealthcare"
includingfamilyplanningcare.Themedicalofficersare
usuallytrainedtoprovideMTPandsterilizationservices.
CurrentlythefamilyplanningmethodsinIndiacan
broadlyclassifiedintwocategories
-
spacingmetnou
limitingpermanentmethods.
(A)Spacingmethods:Thesearereversiblemethods
canbeadoptedanddiscontinuedasperanina
choice,
De
ana
ich
pills
(combined
ora
a
(a)Oralcontraceptives
contraceptivepill(MalaN),Centchroman
(Chna
(6)Condoms
(c)Intrauterinecontraceptivedevices(e
fof
effectivefor10years,IUCD375
5years)
effective
tor
mme)
(d)ContraceptiveinjectableMPA(Antara
progra

136. 595DELIVERY
SYSTEM
Permanentmethod:Thesemethodsareirreversiblein C.AnewmethodofIUCDinsertion(post-partum
!UCD
nsertion)hasbeenintroducedbytheGovernment.
nature
(a)
Female
sterilization
i.
Minilap
ii.
Laparoscopic
d.PromotingPost-partumFamilyPlanningservicesat
districthospitalsbyprovidingforplacement
or
dedicatedFamilyPlanningCounsellorsand
training
or
personnel.
(b)
Male
sterilization
Conventional 3.PregnancyTestingKits
Nischay-Homebasedpregnancytestkits(PTKs)was
launchedunderNRHMin2008acrossthecountry.he
hs
arebeingmadeavailableatsub-centresandtothe
ASHAStofacilitatetheearlydetectionanddecisionmaking
fortheoutcomesofpregnancy.
ii.Nonscalpelvasectomy(noincisionnostitches)
(C)Emergency
contraceptivepills
iringtheyear2018-2019thenumberofacceptorsby
differentmeihodswasasfollows(9):
Sterilization 35.4lakh
4.MissionParivarVikas(MPV)
Aprogrammelaunchedin146hightotalfertilityrate
districtstoacceleratetheuseandawarenessoftamily
planningmethods.Statesanddistrictsfactsheethighlight
thecurrentindicatorsandtrendsinthesedistrictsandwill
Total
1UCD 56.6lakh
22.9lakhPost-partumIUCD
9.9lakhInjectableMPA
****.
14..1lakh
actasbaselineandroadmapforfutureworkinthese
districts,Afiveprongedstrategyhasbeendevelopedunder
themissionparivarvikas,whichcompriseof(9):
Centchroman
Post-abortion1UCD
..
80,165
Performanceofsocialmarketingprogrammeinthesale
of
contraceptiveswas
Condoms
a.Deliveringassuredservices;
b.Building capacity/human
developmentforenhancedservicedelivery;
459.51million additional
resources
Oralpills 159.19cycles
C.Ensuringcommoditysecurity;
Saheli 77.52lakhtablets
d.Implementingnewpromotionalschemes;and
e.Creatinganenablingenvironment.Newinitiatives(114)
1.HomeDeliveryofContraceptives(HDC) 5.Newcontraceptivelaunch(9)
a.Anewschemehasbeenlaunchedtoutilizethe
servicesofASHAtodelivercontraceptivesatthe
doorstepofbeneficiaries.Theschemewaslaunched
in233pilotdistrictsof17Stateson11July2011
andisnowexpandedtotheentirecountryfrom
17thDecember2012.
ThenewcontraceptiveinjectableMPAunder"Antara
programmeandoralcontraceptivepillcentchroman
"chhaya"havebeenaddedtotheexistingcontraceptive
basketofchoicethusprovidingtheuserswithnewoptions.
Thepublicsectorprovidesawiderangeofcontraceptive
servicesforlimitingandspacingofbirthsatvariouslevelsof
healthsystemasdescribedinTable25.b.ASHA ischarginganominalamountirom
beneficiariesforherefforttodelivercontraceptivesat
doorstepi.e.Rs.
1forapackof3condoms.Rs.1fora
cycleofOCPsandRs.2forapackofone'tabletof
ECP
2
Ensuringspacingatbirth(ESB)
a.UnderanewschemelaunchedbytheGovernmentof
India,servicesofASHAstobeutilizedforcounselling
newlymarriedcouplestoensurespacingof2
years
artermarriageandcoupleswithlchildtohave
Spacingof3yearsafterthebirthof1stchild.The
Schemeisoperationalin18States(EAG,North-
casternandGujaratandHaryana).ASHAwouldbe
paidfollowingincentivesunderthescheme
:
GovernmentofIndiaispromoting"FixedDayStatic
Services"(FDS)approachinsterilizationserviceswithinthe
publichealthsystemwiththeaimotincreasingaccessto
sterilizationservices.Statesarebeingprovidedtechnicaland
financialsupportforthedevelopmentofhumanresource:
andupgradationofhealthfacilitiesforthefunctioningo
FDS.Inthestateswithhighunmetneedforlimitingmethods
sterilizationcampswillcontinuetillthetimeFDS
implementedeffectively.Thefrequencyofsterilizatio
servicesatdifferenthealthfacilitiesatFDSisasfollows(96)
Districthospital twiceaweek
Sub-districthospital-weekly
CHC/BlockPHC fortnightly
Rs.500/-toASHAfordelayingfirstchildbirthby
2yearsaftermarriage.
RS.500/-toASHAforensuringspacingot3years
afterthebirthof1stchild.
RS.1000/-incasethecoupleoptsforapermanent
limitingmethodupto2childrenonly.
InistryofHealth&FamilyWelfarehasintroduced
ort
termlUCD(5yearseffectively),CuIUCD375
undertheNationalFamilyPlanningprogramme
rainingofStateleveltrainershasalreadybeen
ompletedandprocessisunderwaytotrainservlce
providersuptothesub-centreleve..
24x7PHC/PHC -monthly
CommunityNeedsAssessmentApproach(115)
Tillrecently,theachievementsoffamilywelf
programmewereassessedonthebasisofthetargetsgiv
fromthecentreforindividualcontraceptives.Thisledte
situationwheretheachievementofthecontraceptivetarg
adbecometheendsbythemselves.Overtheyears=
oecameapparentthatthereweremanydrawbacksinthe
t
downtargetapproachinwhichtypesandquantity
contraceptiveneedtobecanvassedwasdecidedby

137. NATIONALFAMILYWELFAREPROGRAMME 599
level,theInternational
Planned
heinternational
enthoo
A
Federation
istheworld'slargest
private
Pararorganizationsupportingfamilyplanning
servicesvolapingcountries.Itisaninternationalfederationof
wasasignatorytotheAlmaAtaDeclarationin1978.The
acceptanceoftheprimaryhealthcareapproachtothe
achievementofHFA/2000ADledtotheformulationofa
NationalHealth
Policy
in1982.TheNationalHealthPolicy
wasapprovedbytheParliamentin1983.Itlaiddownthe
ong-termdemographicgoalofNRR=1bytheyear2000
-
whichimpliesa2-childfamilynormthroughthe
attainmentofabirthrateof21andadeathrateof9
per
thousandpopulation,andacoupleprotectionrateof60per
centbytheyear2000.TheSixthandSeventhFiveYear
Planswereaccordinglysettoachievethesegoals.The
NationalHealthPolicyalsocalledforrestructuringthe
healthcaredeliverysystemtoachieveHFA/2000AD,and
familyplanninghasbeenaccordedacentralplaceinhealth
development.
Indev
independentFamilyPlanningAssociations
with
dquartersinLondo
Otherswithlongexperienceinthis
AincludetheUnitedNationsFundforPopulationfield
os(UNFPA),theUSAgencyforInternational
Douelopment(USAD),thePopulationCouncil,Ford
Cndation,thePathfinderFundandWorldBankbesides
LO
andUNICEF.Theinternationalagenciesareassisting
in
fundingfamilyplanningresearch,services,training
andinformationprogrammesdesignedtoreducethefamily
size.
NATIONALFAMILYWELFAREPROGRAMME TheUniversalImmunizationProgrammeaimedat
reductioninmortalityandmorbidityamonginfantsand
youngerchildrenduetovaccinepreventablediseaseswas
startedintheyear1985-86.Theoralrehydrationtherapy
wasalsostartedinviewofthefactthatdiarrhoeawasa
leadingcauseofdeathamongchildren.Variousother
programmesunderMCHwerealsoimplementedduringthe
SeventhFiveYearPlan.Theobjectiveofallthese
programmeswereconvergentandaimedatimprovingthe
healthofthemothersandyoungchildren,andtoprovide
themfacilitiesforpreventionandtreatmentofmajor
diseases.During1992theseprogrammeswereintegrated
underChildSurvivalandSafeMotherhood(CsSM)
Programme.
Indialaunched
programmein1952,makingitthefirstcountryintheworld
to
doso,thoughrecordsshowthatbirthcontrolclinicshave
beenfunctioninginthecountrysince1930.Theearly
beginningsoftheprogrammeweremodestwiththe
establishmentofafewclinicsanddistributionofeducational
material,trainingandresearch.DuringtheThirdFiveYear
Plan(1961-66),familyplanningwasdeclaredas"thevery
centreofplanneddevelopment".Theemphasiswasshifted
fromthepurely"clinicapproach"tothemorevigorous
"extensioneducationapproach"formotivatingthepeople
foracceptanceofthe"smallfamilynorm".Theintroduction
oftheLippesLoopin1965necessitatedamajorstructural
reorganizationoftheprogramme,leadingtothecreationof
aseparateDepartmentofFamilyPlanningin1966inthe
MinistryofHealth.Duringtheyears1966-1969,the
programmetookfirmerroots.Thefamilyplanning
intrastructure(e.g.primaryhealthcentres,sub-centres,
urdanfamilyplanningcentres,districtandStatebureaus)
Wasstrengthened.DuringtheFourthFiveYearPlan(1969-
74),theGovernmentofIndiagave"toppriority"tothe
programme.TheProgrammewasmadeanintegralpartof
MCHactivitiesofPHCsandtheirsub-centres.
In1970,an
All
ndiaHospitalPostpartumProgrammeandin1972,the
MedicalTerminationofPregnancy(MTP)Actwere
ntroduced.DuringtheFifthFiveYearPlan(1975-80)there
havebeenmajorchanges.InApril1976,thecountryframed
sirst"NationalPopulationPolicy".Thedisastrousforcible
enlizationcampaignof1976ledtotheCongressdefeatin
ne1977election.InJune1977,thenew(Janata)
overnmentthatcameintopowerformulateda
new
pulationpolicy,rulingoutcompulsionandcoerciontorall
nation-widefamilyplanning
a
Theprocessofintegrationofrelatedprogrammes
initiatedwastakenastepfurtherduring1994whenthe
InternationalConferenceonPopulationandDevelopment
inCairorecommendedimplementationofUnified
ReproductiveandChildHealthProgramme(RCH).Itis
obviouslysensiblethatintegratedRCHprogrammewould
helpinreducingcostofinputstosomeextentbecause
overlappingofexpenditurewouldnolongerbenecessary
andoutcomewillbebetter.Accordingly,duringNinthFive
YearPlantheRCHProgrammeintegratesalltherelated
programmesoftheEighthFiveYearPlan.Theconceptof
RCHistoprovideneedbased,clientoriented,demand
driven,highqualityintegratedservices.
TheGovernmentofIndiaevolvedamoredetailed
andcomprehensiveNationalPopulationPolicy2000(see
page574)topromotefamilywelfare.
Intheyear2005Govt.ofIndialaunchedNationalRura-
HealthMission,initiallyforsevenyears(2005-2012)which
wasextendedfor5yearsupto2017.ThencameNationa
UrbanHealthPlanandmergingboththeseplansa
NationalHealthMission.Intheyear2013,RMNCH+
strategywaslaunchedwhichwasbasedonacontinuumc
careapproachanddefinesintegratedpackagesofservicce
fordifferentstagesoflife.Intheyear2014,IndiaNewbor
ActionPlan(INAP))camewiththegoaltoattainsingledig
neonatalmortalityrateby2030andsingledigitstillbirthrat
by2030.Intheyear2017,NationalHealthPolicywa
launched.
times
COme.
TheMinistryofFamilyPlanningwas
enamed"FamilyWelfare"
lthoughtheperformanceoftheprogrammewaslow
ng1977-78,itwasagoodyearinasmuchasthe
Am
p
memovedintonewhealthierdirections.The42nd
Onment
oftheConstitutionhasmade"Population
Droand
FamilyPlanning"aconcurrentsubject,andthis
acc hasbeenmadeeffectivefromJanuary1977,The
isThelaunching
and
Guidenvolvementofthelocalpeople(e.g.,Health
Ceptanceoftheprogrammeisnowpurelyonvoluntary
Theinvestmentonfamilywelfareprogrammedurin
successiveplan-periodsistabulatedbelow(121).Itcan
seenthatfromamodestsumof0.65croresduringthefi
plan,theinvestmenthasreachedacolossalamount
Rs.371,600croresduringtheTwelfthPlanperiod.
oftheRuralHealthSchemein1977
es,
trainedDais,Opinionleaders)inthefamilywelfare
Togramn
atthegrass levelwereaimedat
accelerating
thepaceofprogressofthe
programme.India

138. preterm
birth
(spontaneous
onsetof
laboor
prelabor
premature
ruptureof
(2)
provider-initiated
pretermbirth(det
laboror
elective
caesareanbirthbef
of
gestation
for
maternalorfetalindi
or
"discretionary"),orother
non-medical
reasons
Spontaneous
pretermbirthis
a
multi-factoria
resultingfromthe
interplay
otfactors
causingtheOCess
change
from
quiescencetoactive
contractionsandus
to
before37
completed
weeksof
gestation.The
nroa.O
birth
spontaneous
pretermbirth
varyby
gest.
and
environmental
factors,butthe
causeof
spontsOClal
pretermlabor
remains
unidentitied
inuptohalfof
ous
Maternailhistoryof
pretermbirthis
astrongriskfactor
most
likelydrivenbythe
interactionofgenetic,eniand
and
environmentalrisk
factors.
oriollowin
OM)
andruptureot
membranes(pPROMIng
definedasnductionnof
before37complet
weeks618
REVENTIVE
MEDICINEIN
OBSTETRICS,
PAEDIATRICS
AND
GERIATRICS
babiescanalsobe
classifiedinto3
groups
accordingto
gestational
age,usingtheword
"preterm","term
and
postterm",
asfollows(29)
dications(both"ur,
ent"
Preterm:
Babiesbornbeforetheendof37
weeks
gestation
(lessthan259days)
b.
ns.
lerm:
Babiesbornfrom37
completed
weeksto
lessthan42
completed
weeks(259to293days)
ofgestation.
sors
to
Postterm:Babiesbornat42
completed
weeksor
anytime
thereafter(294daysand
over)of
gestation.
stationalage,
case
ALBWinfantthen,isanyinfantwithabirthweightof
lessthan2.5kgregardlessof
gestationalage.
Itincludestwo
kindsofinfants:
igeenetic
Elevatedriskofpretermbirthalsodemandsincrea
attention
tomaternal
health,
includingthearnted
diagnosisand
managementotNCDsandotherconditio
knowntoincrease
theriskotpretermbirth.Premahw
babies,inturn,areatgreaterriskofdevelopingNCDs.li
hypertensionanddiabetes,
andother
significanthealth
conditionlaterinlite,creatinganintergenerationalcycle
of
risk.Thelinkbetweenprematurityandanincreasedriskof
NCDstakesonanadded
publichealthimportancewhen
consideringthereportedincreaseintheratesofboth
worldwide.Table4summarizesthetypesofpretermbirths
andtheriskfactorsinvolved.
PRETERMBABIES(9)
enata
Pretermisdefinedasbabiesbornalivebefore37weeks
of
pregnancyare
completed.Thereare
sub-categoriesof
pretermbirth,basedongestational
age
extremelypreterm(<28
weeks)
verypreterm(28to<32weeks)
moderatetolatepreterm(32to37weeks).
Thesearebabiesborntooearly.Theirintrauterine
growthmaybenormal.Thatis,theirweight,lengthand
developmentmaybewithinnormallimitsforthedurationof
gestation.Givengoodneonatalcare,thesebabiesmaycatch
upgrowthandby2to3yearsofagewillbeofnormalsize
andperformance.
TABLE4
Typesofpretermbirthandriskfactorsinvolved
INCIDENCE Examples:
Morethan
1
in10oftheworld'sbabiesbornin2015were
bornprematurely,makinganestímated15millionpreterm
births(definedasbefore37weeksofgestation)ofwhich
morethan
1
milliondiedasaresulfoftheirprematurity.
Prematurityisnowthesecond-leadingcauseofdeathin
childrenunder5years,andthesinglemostimportantcause
ofdeathinthecriticalfirstmonthoflife.Forthebabieswho
survive,manyfacealifetimeofsignificantdisability.
Pretermbirthsisaglobalproblem.More1han60percent
ofpretermbirthsoccurinAfricaandSouthAsia.Inthelower
incomecountries,onaverage,12jpercentbabiesareborn
tooearlycompared1o9percentinhigher-incomecountries.
Withincountries,poorerfamiliesareathigherrisk.The
10countrieswiththegreatestnumberofpretermbirthsin
2015
are:(1)India3519100;(2)China1172300:(3)Nigeria
773600;(4)Pakistan748100;(5)Indonesia675700;(6)USA
517400;(7)Bangladesh424100;(8)Philippines348900;
(9)DPRoftheCongo341400;and(10)Brazil279300(31).
Type: RiskFactors:
SponlaneousAgeatpregnancy
andpregnancy
spacing
Adolescentpregnancy,
advancedmaternalage,
orshortinter-pregnancy
interval
pretetmbirth;
Incrcasedratesoftwinand
higherorcderpregnancies
withassistedreproduction
Multiple
pregnancy
Infection Urinarytractinfections,
malaria,HIV,sypihilis,
bacterialvaginosis.
Underlying
maternalchronic
nedicalconditions
Diabetes,hypertension,
anaemia,asthma,thyroid
disease
Nutritional Undernutrition,obesity,
micronutrientdeficiencies
Lifestyle
workrelated
Smoking,excessalcohol
consumption,recreational
druguse,excessphysical
work/activity
The10countrieswiththehighestratesofpretermbirth
per100ivebirthsis;(1)Malawi18.1;(2)Comoros16.7:
(3)Congo16.7;(4)Zimbabwe16.6:(5)EquatorialGuinea
16.5;(6)Mozambique16.4;(7)Gabon16.3;:(8)Pakistan
15.8:(9)Indonesia15.5;and(10)Mauritania15.4(31).
Thereisadramaticdifferenceinsurvivalofpremature
babiesdependingonwheretheyareborn.Morethan90per
centofextremelypretermbabies(lessthan28weeks)born
inlow-incomecountriesdiewithinthefirstfewdaysoflife;
yetlessthan10percentofextremelypretermbabiesdiein
highincomecountries.
Maternal
psychological
health
Depression,violence
againstwomen
GeneticandotherGeneticrisk,e.g.,family
history,Cervical
incompetence
Provider-
initiated
pretermbirth:
Medicalinduction
orcaesareanbirth
forobstetric
indication,Foetal
indication
Thereisanoverlapfor
indicatedprovider-initia
pretermbirthwiththeris
factorsforspontaneous
pretermbirth.Causesofpretermbirths(9)
Pretermbirthisasyndromewithavarietyofcauses
which
canbeclassifiedintotwobroadsubtypes:(1)spontaneous
Other-Notmedically
indicated
Source
(9)

139. 619
OW
BIRFH
WEIGHT
Someoftheproblemsprematurebabiesmayexperience
include(34):
Temperatureinstabilityinabilitytostaywarmdueto
lowbodyfat
ALL-FOR-DATE(SFD)BABIES
Also
nownassmall
may
10th
percentile
forgestationalagebabies.These
bornattermorpreterm.Theyweighlessthanthe
be
gestationalage.Thesebabiesare
10tn
the
resultofretardedintrauterinefoetalgrowth.
Respiratoryproblems;
hyaline
membrane
disease/respiratorydistress
syndromeaconditioninwhichtheairsacs
cannot
stayopenduetolackofsurfactantinthelung
chroniclung
disease/bronchopulmonarydysplasia
long-termrespiratoryproblemscausedbyinjurytothe
lungtissue
ComputationThepercentageofLBW
babiesis
computedas
Live-bornbabieswithbirthweightlessthan2.5Kg
x100
Totalnumberoflivebirths
ThefactorsassoCiatedwithintrauterinegrowth
otardationaremultipleandinterrelatedtomother,the
lacentaortothetoetus.Thematernalfactorsinclude
malnutrition,severeanaemia,heavyphysicalworkduring
Dregnancy,hypertension,malaria,toxaemia,smoking,low
oconomicstatus,shortmaternalstature,veryyoungage,
hioh
parityandclosebirthspacing,loweducationstatusetc.
132).Theplacentalcausesincludeplacentalinsufficiency
andplacentalabnormalities.ihefoetalcausesincludefoetal
abnormalities,intrauterine
abnormalityandmultiplegestation.
SFDbabieshaveahighriskofdyingnotonlyduringthe
neonatalperiodbutduringtheirinfancy,thussignificantly
raisingtherateofintantandperinatalmortalityand
contributegreatlytoimmediateandlongtermhealth
problems.Mostofthembecomevictimsofprotein-energy
malnutritionandinfections.
-airleakingoutofthenormallungspacesintoother
tissues
incompletelungdevelopment
apnea(stoppingbreathing)occursinabouthalfof
babiesbornatorbefore30weeks
Cardiovascular
-patentductusarteriosus(PDA)
-aheartcondition
thatcausesbloodtodivertawayfromthelungs
toolowortoohighbloodpressure
lowheartrate
-
oftenoccurswithapnea
.Bloodandmetabolic;
infections,chromosomal
anaemia-mayrequirebloodtransfusion
jaundicedue toimmaturityofliverand
gastrointestinalfunction
-toolowortoohighlevelsofmineralsandother
substancesinthebloodsuchascalciumandglucose
(sugar)
Inthedevelopingcountries,adverseprenatalandpost-
nataldevelopmentofthechildisassociatedwith
3interrelatedconditionsmalnutrition,infectionand
unregulatedfertilitywhichareoftenduetopoorsocio
Gastrointestinal;
-difficultyfeedingmanyareunabletocoordinate
suckandswallowbefore35weeksgestation
economicandenvironmentalconditions.
poordigestion
necrotizingenterocolitis(NEC)
-aseriousdiseaseof
theintestinecommoninprematurebabies
IMPORTANCE
LBWisoneofthemostseriouschallengesinmaternaland
childhealthinbothdevelopedanddevelopingcountries.Its
publichealthsignificancemaybeascribedtonumerous
factorsitshighincidence;itsassociationwithmental
retardationandahighriskofperinatalandinfantmortality
andmorbidity(halfofallperinatalandone-thirdofallinfant
deathsareduetoLBWw);humanwastageandsuffering;the
veryhighcostofspecialcareandintensivecareunitsandits
associationwithsocio-economicunderdevelopment(33).
Neurologic;
intraventricularhaemorrhage
-bleedinginthebrain
-periventricularleukomalacia
-softeningoftissuesof
thebrainaroundtheventricles(thespacesinthebrain
containingcerebrospinalfluid).
-poormuscletone
seizuresmaybeduetobleedinginthebrain
retinopathyofprematurityabnormalgrowthofthe
bloodvesselsinababy'seye
LBWisthesinglemostimportantfactordeterminingthe
Survivalchancesofthechild.Manyofthemdieduringtheir
irstyear.Theinfantmortalityrateisabout20timesgreater
or
al
LBWbabiesthanforotherbabies.Thelowerthebirth
weight,theloweristhesurvivalchance.Manyofthem
comevictimsofprotein-energymalnutritionand
ection.
LBWisthusanimportantguidetothelevelofcare
Heededbyindividualbabies.LBWalsoreflectsinadequate
ritionandill-healthofthemother.Thereisastrongand
iticantpositivecorrelationbetweenmaternalnutritional
ausandthelengthofpregnancyandbirthweight.Ahigh
ercentageofLBWthereforepointstodeficienthealthstatuscause-specific.ain
attentionhasbeengiveninrecent
fregnantwomen,inadequateprenatalcareandtheneed
Infectionsprematureinfantsaremoresusceptibleto
infectionandmayrequireantibiotics
PREVENTION
ExpertsopinethattheratesofLBWbabiescouldbe
reducedtonotmorethan10percentinallpartsofthe
world(35).Itisclearfromthemultiplicityofcausesthat
thereisnouniversalsolution.Interventionshavetobe
yearstowaysandmeansofpreventingLBWthroughgood
prenatalcareandinterventionprogrammes,
ratherthan
"treatment"ofLBWbabiesbornlater.
1Or
improved
careofthenewborn.
Prematurebabiesarebornbeforetheirbodiesand
heahstemshavecompletelymatured,they
mayneedDIRECTINTERVENTIONMEASURES
Veru
aning,eating,fightinginfectionandstayingwarm.
Teady
forlife
utsidethe
immature
tofunction
well.
premature
abieswhoarebornbefore28weeks,are
eciallyvulnerablManyoftheirorgansmaynotbe
TheincidenceofLBWcanbereducedifpregnantwomen
"atrisk"areidentifiedandstepsaretakentoreducetherisk.
Forthisapproachthewomenneedtobeidentifiedearlyin
pregnancy.Toachievethisgoal,themothershealthcard
-
mother'suterusandmaybetoo

140. NATIONALPOLICYFORCHILDREN 637
Theobjectivesottneschemeare:(1)Improveaccesstoo
andqualityofchildprotectionservices;(2)Raisepublic
arenessaboutchildrights;(3)Clearlyarticulated
responsibilitiesandaccountabilityforchildprotection;
4)Establishstructuresatallgovernmentlevelsfor
deliveryotstatutoryandsupportservicestochildrenin
difficultcircumstances,and
)Setting-upofan
evidencebasedmonitoringandevaluationsystem.
10,ProtectionofChildrenfromSexualOffences(POCSO)
Act,2012
Inordertoeffectivelyaddresstheheinouscrimeot
sexualabuseandsexualexploitationofchildren
tnroughlessambiguousandmorestringentlegal
provisions,theMinistryofWomenandChild
DevelopmentintroducedtheProtectionofChildren
fromSexualOffences(POCSO)Act,2012.
TheActdefinesachildasanypersonbelow18yearsof
age
andregardsthebestinterestandwell-beingofa
childasbeingofparamountimportanceateverystage
toensureahealthyphysical,emotional,intellectual
anasocialdevelopmentofthechild.Itdetinesditterent
formsofsexualabuse,includingpenetrativeandnon
penetrativeassault,aswellassexualharassmentand
pornography,anddeemsasexualassaulttobee
aggravated"undercertaincircumstances,suchas
whenabusedchildismentallyillorwhentheabuseis
committedbyapersoninapositionoftrustor
authorityvis-a-visthechild,likeafamilymember,
policeofficer,teacherordoctor.Peoplewhotraffic
childrenforsexualpurposearealsopunishableunder
theprovisionsrelatingtoabetmentinthesaidAct(68).
TheservicesprovidedunderICPSareasfollows
(1)Emergencyoutreachservicethrough'Childline',
dedicatednumberis1098.Itisa24-hourtollfree
telephoneserviceavailabletoallchildrenindistress.
(2)Opensheltersforchildreninneed,inurbanand
semi-urbanareas.
(3)Familybasednon-instifutionalcarethrough
sponsorship,foster-care,adoption,cradlebaby
centresandafter-care.
(4)Institutionalservicesthroughshelterhomes,children
homes,observationhomes,specialhomes,and
specializedservicesforchildrenwithspecialneeds.
(5)Web-enabledchildprotectionmanagementsystem
includingwebsiteformissingchildren.
(6)Generalgrant-in-aidforneedbasedinterventions.
Anordinanceprovidingthedeathpenaltyforrapistof
girlsbelow12yearsofage"TheCriminalLaw
AmendmentOrdinance,2018waspromulgated.The
salientfeaturesoftheOrdinanceare:
9.NationalPolicyforChildren2013(NPC)(67)
TheNationalPolicyforChildren2013isalongterm
Sustainable,multi-sectoral,andintegratedapproach
forthedevelopmentandprotectionofchildreni.e.
a.Minimumpunishmentforrapemade10years;
b.Minimumpunishmentof20yearstoaperson
commitingrapeonagirlagedbelow16years;
C.Minimumpunishmentof20yearsrigorous
imprisonmentandmaximumdeathpenalty/life
imprisonmentforcommittingrapeonagirlaged
below1Zyears,
d.Policeotticercommittingrapeanywhereshallbe
awardedrigorousimprisonmentofminimum
10years
e.Investigationofrapecasestobecompletedwithin
2months;
0-18yearsagegroup.Survival,health,nutrition,
development,education,protectionandparticipation
arethekeyprioritiesofthepolicy.Itreiteratesthe
State'scommitmenttoensureuitableaccessto
essential,preventive,promotive,curativeand
rehabilitativehealthcareforallchildren.Towardsthis
goal,NPCenvisagesthatstateshalltakemeasuresto:
Improvematernalhealthcare(pre-natal,natal,
post-natal);
Provideuniversalaccesstoservicesforintormed
choicesrelatedtobirthsandspacing;
Addresskeycausesofchildmortalitythrough
appropriateinterventionsincludingaccesstosate
drinkingwaterandsanitation
Toimprovenewbornandchildcarepractices
Toprotectchildrenfromwaterborne,bloodborne,
vectorborne,communicableandotherchildhood
aiseasesbyprovidinguniversalandaffordable
ess
toappropriateservices;
Preventdisabilities,physicalandmentalthrough
timelymeasurestotakepre-natal,natal,perl-natal
andpost-natalcareofmotherandchild;
Cnsureavailabilityofservices,supportand
provisionsfornutritiveattainmentinalifecycle
approachwithfocusoninfantandyoungchild
eeding(IYCF)practicesandonthehealthand
nutritionneedsofadolescentgirlsandother
Vulnerablegroups
PreventHIVinfectionsatbirthandensureproper
treatmenttoinfectedchildren;and
rovidetheadolescentsaccesstoinformationenders
derween5
and18yearsof
ageshouldhe
e
rding
illeffectsofalcoholandsubstanceuse,
andsupportforthechoiceofhealthylifestyle.
tate
commitstoallocatetherequiredfinancial,
ofa
andhuman
resourcesfortheimplementation
PC
2013.TheMinistryofWomen&
Child
Opment
isthenodalministryforimplementationdI5tressand
the
aicult
circumstancesoftheirchildhoode
Appealsinrapecasestobedisposedwithin6
months;and
Noanticipatorybailcanbegrantedtoaperson
accusedofrapeofgirlofagelessthan16years.
ThePOCSOAct2012wasfurtherammendedintheyear
2019withinsertionofthefollowingclause:
UndertheAct,apersonisguiltyof
usingachildfor
pornographicpurposesifheusesachildinanyformofmedia
forthepurposeofsexualgratitication.TheActalsopenalises
personswhousechildrenforpornographicpurposesresulting
insexualassault.TheBilldetineschildpornographyasany
visualdepictionotsexuallyexplicitconductinvolvingachild
includingphotograph,vide0,digitalorcomputergenerated
imageindistinguishableiromanactualchild.Thepunishment
isminimum5years
inJa.
IheActpenalisesstorageof
pornographicmaterial
1or
commercialpurposeswitha
punishmentofuptothreeyears,oratineorboth(68A).
ThePOCSOammendmentBill2020proposesthatchild
undertheambitofthePOCSOAct2012andbegiventhe
samepunishmentasisgiventoadults(68B).
Thegrowingvulnerabilityofchildreninurbansettlements,
includingthosecaught
intheshittingframeofmigratoryand
transientlabourare
alsonowintheMWCDportfolio.Their
ofNPC.
meritspecialmeasuresofdevelopmentandprotection.
,
1
1

141. 640
HEVENTIVE MEDUCINEINMSTTRcs,ADIATRICSANVGERIATRIES
TABLE11
MCIIgoalsandcentleclofaclhievement(media)
EET
AGoalsandtargetperiod
Indicator
Current
ThreeYearActlonAgendaNationalHealthSustainablen
ofNitlAyog(2018-19-20)Policy2017 D
0als ls(2030men
level eloprment
AFamilyPlanningIndicators
Crudebirthrate
Totalfertilityrate
21
20.0(2018)
2.2(2018)
67.0(2015-19)
2.12.1
by2025
MeetallneedsCoupleprotectionrate(
B.Mortalityindicatorsper1000
lnfantmortality
Neonatalmortality
Maternalmortalityper100,000
Under-5mortality
C.Services(coverage)
Infantsimmunized(2018)
-Measles
-DPT
-Polio
-BCG
-HepB,
Hib,
-Rotavirus
-PCV
PregnantwomenTT
Antenatalcarecoverage%
atleastonce
atleastfourtimes
28by2019
16by2025
100by2020
23by2025
3032(2018)
23(2018)
113(2016-18)
36(2018)
12
120
70
S25
38
90by2025
80
89
89
92
89
89
35
6
87.0
100(2013-2018)
79.0
51.0
90
Institutionaldeliveries 8079.0(2013-2018)
81.0(2013-2018)
D.Prevalenceoflow-birth-weightbabies28(2011-2016)
Deliveriesbytrainedpersonnel gTS 100 i
Source:(5,69)
restructuringthehealthservices,basedonprimaryhealth
careapproachwithshortandlong-termgoals.
MunicipalCorporationsandvoluntaryorganizations,TH
servicesofobstetriciansareavailableatdistricthospita
whicharetheapicalhospitalstorMCHcareatthedistr
level.Forspecializedcareofchildren,paediatric
units
ha-
beenestablishedinseveraldistricthospitals.
Table12showstheevolutionofmaternalandc
healthprogrammesinIndia.
Theinfrastructureinruralareasisbasedonthecomplexof
communityhealthcentres,primaryhealthcentresandtheir
subcentres.Theyprovidepreventiveandpromotivehealth
careservices.Sincedeliveriesbytrainedhealthpersonnels
arecrucialinreducingmaternalandinfantmortalityinrural
areas,thegovernmentofIndiaundertookaschemetotrain
localdaistoconductsafedeliveries.Thesedaisarenow
availableinmostvillages.MentionmustbemadeofICDS
(IntegratedChildDevelopmentServices)projectswhichare
functioningalloverthecountryprovidingapackageofbasic
healthservices(eg.supplementarynutrition,immunization,
healthcheck-up,referral,nutritionandhealtheducation,and
non-formaleducationservices)tomotherandchildren.
TABLE12
Evolutionofmaternalandchildhealthprogrammesin
ir-
Year 1is
Milestones
1952 FamilyPlanningprogrammeadoptedbyGovernme
India(GOI)
1961DepartmentofFamilyPlanningcreatedinMinistry
Maternalhealthcare
wasapartoffamilywelfare
programmefromitsinception.Interventionswereintroduced
onverticalschemes,butfamilyplanningremaineda
separateintervention.In1992,theChildSurvivalandSafe
MotherhoodProgrammeintegratedalltheschemesforbetter
compliance.Morerecently,ReproductiveandChildHealth
Programmewaslaunchedin1997,whichintegratedfamily
planning,ChildSurvivalandSafeMotherhoodProgramme,
PreventivemanagementofSTD/RTI,AlIDS,andaclient
approachtohealthcare.Thisprogrammehasenteredinto
phaseII,withreorientationtomakeitconsistantwiththe
requirementoftheNationalRuralHealthMission.
Health
1971 MedicalTerminationofPregnancyAct(MTPAct),?
RenamingofFainilyPlanningtoFamilyWelfare
ExpandedProgrammeonImmunization(EPI)
1985 UniversalImmunizationProgramme(UIP)+
sNationalOralRehydrationTherapy(ORT)Progra
1992 ChildSurvivalandSafeMotherhoodProgramme
1977
1978
(CSSM)
Target-freeapproach
ReproductiveandChildHealthProgramme-1
(RC
ReproductiveandChildHealthProgramme-2(R
NationalRuralHealthMission
RMNCH+AStrategy
1996
1997
2005
2005
2013
Inurbanareas,thegeneraltrendistowardsinstitutional
delivery.Inlargercities,almost90percentofdeliveries
takeplaceinmaternityhospitalsandmaternityhomes.
Someoftheinstitutionsareundertheauspicesofthe
2013NationalHealthMission
2014IndiaNewbornActionPlan(INAP)
Source:(70)

142. INDICATORSOF
MCHCARE 641
INDICATORSOFMCHCARE
six-week(42day)postpartumperiod,andtheincreased
availabilityofmodernlife-sustainingproceduresand
TechnologiesenablesmorewomentosurvIveadvee
outcomesofpregnancyanddelivery,andalsodelayssome
deathsbeyondthatpostpartumperiod.Specificcodesfor
atematernaldeaths",areincludedintheICD-10(096and
097)tocapturethesedelayedmaternaldeaths,whichmay
notbecategorizedasmaternaldeathsincivilregistration
andvitalstatisticssystemsdespitebeingcausedby
pregnancy-relatedevents.
healthstatusisassessedthrough
Maternalandchild
ofmortalitymorbidity
and,growthand
Inmanycountriemortalityratesarestillthe
asurements
development.
0or
standardized.Inrecentyears,attentionhasbeenpaid
o
systematizing
only
sourceofintormation.Morbidity
dataarescarce
and
thecollection,
interpretation
and
0inationofdataongrowthanddevelopment.The
rommonsedmortalityindicatorsofMCHcareare
1.Maternalmortalityratio
2.Mortalityininfancyandchildhood
a.Perinatalmortalityrate
b.Neonatalmortalityrate
C.Post-neonatalmortalityrate
d.Infantmortalityrate
e.1-4yearmortalityrate
f.Under-5mortalityrate
g.Childsurvivalrate.
Maternaldeathsandlatematernaldeathsarecombined
inthe11threvisionoftheICDunderthenewgroupingof
"comprehensivematernaldeaths".
Pregnancy-relateddeath(alsoknownasdeathoccurring
duringpregnancy,childbirthandpuerperium):isdefinedas
hedeath
ofawomanwhilepregnantorwithin42daysof
terminationofpregnancy,irrespectiveofthecauseofdeath
(obstetricandnon-obstetric)";thisdefinitionincludes
unintentional/accidentalandincidentalcauses.
his
definitionallowsmeasurementofdeathsthatoccurduring
pregnancy,childbirthandpuerperiumwhileacknowledging
thatsuchmeasurementsdonotstrictlyconformto
the
standard"maternaldeath"conceptinsettingswhere
accurateinformationaboutcausesofdeathbasedon
medicalcertificationisunavailable(1).
MATERNALMORTALITYRATIO
AccordingtoWHO,amaternaldeathisdefinedas"the
deathofawomanwhilepregnantorwithin42daysof
terminationofpregnancy,irrespectiveofthedurationandsite
ofpregnancy,fromanycauserelatedtooraggravatedbythe
pregnancyoritsmanagementbutnotfromunintentionalor
incidentalcauses"(1).
Thenumberofmaternaldeathsinapopulation(duringa
specifiedtimeperiod,usuallyonecalendaryear)reflectstwo
factors:(i)theriskofmortalityassociatedwithasingle
pregnancyorasinglebirth(whetherlivebirthorstillbirth):
and(ii)thefertilitylevel(i.e.thenumberofpregnanciesor
birthsthatareexperiencedbywomenofreproductiveage,
i.e.age15-49years).
Maternalmortalityratio(MMR):isdefinedasthe
numberofmaternaldeathsduringagiventimeperiodper
100,000livebirthsduringthesametimeperiod;thus,it
quantifiestheriskofmaternaldeathrelativetothenumber
oflivebirths,andessentiallycapturesthefirstfactor
mentionedabove(1).
Thisdefinitionallowsidentificationofamaternaldeath,
basedonthecauseofthedeathbeingidentifiedaseithera
directorindirectmaternalcause.Itiscalculatedas
Totalno.offemaledeathsdueto
complicationsofpregnancy,childbirthor
within42daysofdeliveryfrom"puerperal
causes"inanareaduringagivenx1000(or100,000)
Totalno.oflivebirthsinthesame
areaandyear
Directobstetricdeaths(ordirectmaternaldeaths)those
resultingfromobstetriccomplicationsofthepregnantstate
pregnancy,
labourandpuerperium),frominterventions
omissions,
incorrecttreatment,orfromachain
of
eventsresultingfromanyoftheabove.Deathsdue
too
obstetric
haemorrhageor
PEgnancy,forexample,orthoseduetocomplications
of
Estnestaorcaesareansectionareclassitiedasdirect
maternaldeaths(1).
Maternalmortalityrate(MMRate)isdefinedand
calculatedasthenumberofmaternaldeathsdividedby
person-yearslivedbywomenofreproductiveageina
population.TheMMRatecapturesboththeriskofmaternal
deathperpregnancyorperbirth(whetherlivebirthor
stillbirth),andtheleveloffertilityinthepopulation(i.e.
bothfactorsmentionedabove)(1).
hypertensivedisordersin
Adultlifetimeriskofmaternaldeathforwomeninthe
population,isdefinedastheprobabilitythata15year-old
girl(intheyearoftheestimate)willeventuallydiefromha
maternalcause.Thisindicatortakesintoaccountcompeting
causesofdeath(1).
Theproportionofmaternaldeathsofwomenof
reproductiveage(PM):Thenumberofmaternaldeathsina
giventimeperioddividedbythetotaldeaths,among
womenaged15-49years.
The43rdWorldAssemblyin1990adoptedthe
recommendationthatcountriesconsidertheinclusionon
deathcertificatesofquestionsregardingcurrentpregnancy
andpregnancywithinoneyearprecedingdeathinorderto
improvethequalityofmaternalmortalitydataandprovide
alternativemethodsofcollectingdataondeathsduring
pregnancyorrelatedtoit,aswellastoencouragethe
recordingofdeathsfromobstetriccausesoccurringmore
than42daysfollowingterminatiornofpregnancy.
ndirectobstetricdeaths(orindirectmaternaldeaths)
resultingfrompreviousexistingdiseaseordiseasethat
ieveloped
duringegnancyandwhichwasnotduetodirect
obstetriccauses,
butwhichwas
aggravatedbyphysiological
s
Ofpregnancy.Forexample,deathsduetoaggravation
Pregnancy)ofanexistingcardiacorrenaldisease
are
Onsideredindirectmaternaldeaths.
ho
Th
maternalmortalityrate,thedirectobstetricrateand
mateCt
obstetricratearefinemeasuresofthequality
Of
maternity
services.
dirertaternaldeath:Itis"thedeathofawomanfromLate
butleserect
obstetriccauses,aftermorethan42days
lessthanoneyeaafterterminationofpregnancy"(1).
direct
andindirectternal/obstetricdeaths.
Complications
aldeaths,latematernaldeathsalsoincludeboth
ofpre
ancyorchildbirth
can
leadtodeathbeyondthe

143. 642 NEVENTVE MEDICINEINORSTETRICS,PAEDIATRICSANDGERIATRICS
Approachesformeasuringmaternalmortality(1)
Intheabsenceofcompleteandaccuratecivilregistration
Systems,MMR
estimatesarebaseduponavarietyofmethods
(1)CivilregistrationsystemsThisapproachinvolves
routineregistrationofbirthsanddeaths.Ideally,materna
mortalitystatisticsshouldbeobtainedthroughcivil
registrationdata.
achievedthegreatepercentage
reduction
i
Between2000and2017,the
sub.roet.
ion
of
Souh
Northern
ae
384to157(59percent).CentralAsia(59MMR,
Asia(50percent),Europe(53percent
).Cent
(54percent)halvedtheirMMR
during
that
periodAwomanismostvulnerableatthepost.
About50-70percentaternal
deaths
st-parlum
pe
postpartumperiodofwhich(2)Householdsurvey:Wherecivilregistrationdataare
notavailable,householdsurveyprovidesanalternative.
(3)Sisterhood
methodsSisterhoodmethodsobtain
informationbyinterviewingarepresentativesampleof
respondentsaboutthesurvivalofalltheiradultsisters(to
determinethenumberofevermarrriedsisters,howmany
arealive,howmanyaredead,andhowmanydiedduring
pregnancy,delivery,orwithinsixweeksofpregnancy.
(4)Reproductive-agemortalitystudies(RAMOS) :This
approachinvolvesidentifyingandinvestigatingthecauses
ofalldeathsofwomenofreproductiveageinadetined
area/populationbyusingmultiplesourcesofdata.
(5)Verbalautopsy
:Thisapproachisusedtoassigncause
ofdeaththroughinterviewwithfamilyorcommunity
members,wheremedicalcertificationofcauseofdeathis
notavailable.Recordsofbirthsanddeathsarecollected
first24hoursatterdeliveryandmorethantu
thefirstweek.Between11-17per
centof
OcOr
in
percent
deaths
occuri
occurduringchildbirthitself(71). ternal
dez
Maternalmortalityratiosstrongly
reflect
thoeffectivenessofhealthsystems,which
in
the
ov
lovdevelopingcountriessutterfrom
weaka-technicalandlogisticalcapacity,inadeua-
invesmentandalackofskilledhealthpersonnel
financ
Scalkeyinterventions
-
forexample,increasing
the
n
birthsattendedbyskilledhealthpersonnel,.providinoa
ng
aesemergencyobstetriccarewhennecessary
andprovidina
natalcareformothersandbabies-couldsharnlrr
reduceba
periodicallyamongsmallpopulations,underdemographic
surveillancesystemsmaintainedbytheresearchinstitutions
indevelopingcountries.
(6)Census:Anationalcensus,withtheadditionofalimited
numberofquestions,couldproduceestimatesofmaternal
mortality;thisapproacheliminatessamplingerrorsandhence
allowsamoredetailedbreakdownoftheresults,includingtime
trends,geographicsubdivisionsandsocialstrata.
maternalandneonataldeaths.Enhancing
women's
aCre
familyplanning,adequatenutrition,improvedwater-
sanitationfacilitiesandaffordablebasichealthcareproteri
fromabuse,violene,discrimination,empowerment
ofwome
greaterinvolvementofmeninmaternalandchild
care.
we
lowermortalityratesfurtherstill.Thesearenotimposit
impracticalactions,butproven,cost-eftectiveprovision
womenofreproductiveagehavearighttoexpect.
Thelowstatusofwomeninthesocietycoupledwitht=
lowliteracylevelspreventthewomenfromtakingantena
careevenifservicesareavailable.Mostdeliveriestake
pam
athomewithouttheservicesofthetrained
miduile=
Incidence
personnel.Thereisaninverserelationshipbetweenliatir
riskofmaternaldeathandtheavailabilityofthetraits
healthworkerduringpregnancyandatthetimeofdelive
WORLDSCENARIO
ThemethodologyemployedbytheMaternalMortality
EstimationInter-AgencyGrouptoestimate1990-2015
maternalmortalityratiofollowedanimprovedapproach
referredtoasBayesianmaternalmortalityestimationmodel
orBMatmodel.Theseresultssupersedeallpreviously
publishedestimatesfortheyearswithinthattimeperiodand
differenceswithpreviouslypublishedestimatesshouldnot
beinterpretedasrepresentingtimetrends(1).
Anestimated295,000maternaldeathsoccurredglobally
in2017,yeildinganoverallMMRof211(199-243)
maternaldeathsper100,000livebirths.Theglobaladult
life-timeriskofmaternalmortality(i.e.theprobabilitythata
15yearsoldwomanwilldieeventuallyfromamaternal
cause)isapproximately
1
in190fortheyear2017.Forthe
purposeofcategorization,MMRisconsideredtobehighifit
is300-499,veryhighifitis500-999,andextremelyhighif
itis21000maternaldeathsper100,000livebirths(1).
MMRintheworld'sleastdevelopedcountriesishigh,
estimatedat415maternaldeathsper100,000livebirths
whichismorethan40timeshigherthanMMRinEurope
(10),andalmost60timeshigherthaninAustraliaandNew
Zealand(7).Thelifetimeriskofmaternaldeathinleast
developedcountriesis
1
in56,SubSaharanAfricaisthe
onlyRegionwithveryhighMMRfor2017,estimatedat542
withlife.timeriskofmaternaldeathat1in37.Three
countriesnamely,SouthSudan(1150),Chad(1140)and
SierraLeone(1120)fallunderextremelyhighMMRin2017.
Nigeria(67000)andIndia(35000)hadthehighestestimated
numberofmaternaldeathsaccountingforapproximately
35percentofestimatedglobalmaternaldeaths(1).
Itisatragicsituationasthesedeathsarenot
caused
diseasebutoccurredduringorafteranaturalproces.i
oneoftheleadingcauseofdeathforwomenofreprodu
ageinmanypartsoftheworld.Mostmaternaldeaths
arm
pregnancycomplicationscanbepreventedif
prey
Womenhaveaccesstogood-qualityantenatal,
natald
postnatalcare,andifcertainharmfulbirthpractices
avoided.Estimatesofantenatalcare
coverage.d
conductedbyskilledpersonnel,lifetimeriskofm
deathandmaternalmortalityratioinsome
developing
developedcountriesareshowninTable13.
Maternalhealth,however,goesbeyondthe
urvival
pregnantwomenandmothers.Forevery
woiatina
romcausesrelatedtopregnancyorchildbirth,itin
thatthereare20otherswhosufferpregnan
elated
number
i
orexperienceothersevere
consequences.
aly
million
women
annua
Survivetheirpregnanciesexperience
suchadvet
verse
outcomestriking:Anestimated10
Causes
Maternaldeathsmostlyoccurfromthe
third
trimester
(withtheexceptionof
deaths
due
ortality
risk
thefirstweekafterbirth
complicationsofabortion).
formothersareparticularlyelevatedwithin
the
first
to
two
obs
Studiesshowthati
etm
afterbirth.Mostmaternaldeathsare
relate
infections,eclampsiaand
olongedor
bstructed
labo
haemoritha4
complicationsincluding
postpartum
direct
causes
heae
andcomplicationsofabortion.
Mostot
se
skilled
maternalmortalitycanbereadilyaddres>

144. 643
INDICATORSOFMCHCARE
TABLE13
Maternalmortalityratio.deliveriesconductedbyskilledpersonnel,antenatalcareove
andlitetimeriskotmaternaldeathsinsomedevelopinganddevelopedcouu
e
Antenatalcare Maternalmortality
Deliveriesconductedby
skilledpersonnel(%)
Counry Lifetimerisk
coverage(%)(2013-2018)
Atleastonce Aileastfourtimes
ratio(per100,000
livebirths)(2017)
maternaldeath
(2013-2018)
(onein)(2017)
113(2016-18)
173
9
81 290
64 31 42 250
Bangiadassh
98 85
75 250
183
Bhutan
98 77
94 240
177
ndonesa
81 59 60 190
195
yanmar
84 69 58 186
220
Nepal
98 91 99 1,900
37
Thaiand
99 93 100 1,300
36
Si
Lanka
86 51 69 140
188
Pakistan
100 81 100 2,100
29
China
100 100 100 16,700
Japan
100 100 100 9,900
Singapare
UK 99 8,400
97 99 3,000
19
USA
86 65 81 190 211
World
Source:(72)
personnelareonhandandkeydrugs,equipmentand
referralfacilitiesareavailable.
treatmentwithrelativelysimpleanticonvulsantdrugsin
casesofeclampsia.
About80percentofmaternaldeathsareduetodirect
causesi.e.obstetriccomplicationsofpregnancy,labourand
puerperiumtointerventionsorincorrecttreatment.Asshown
inFig.10thesinglemostcommoncause-accountingfora
quarterofallmaternaldeathsisobstetrichaemorrhage,
generallyoccurringpostpartumwhichcanleadtodeathvery
rapidlyintheabsenceofpromptlife-savingcare.
Oftheestimated210millionpregnanciesthatoccur
everyyear,about42millionendininducedabortion,of
whichonlyapproximately60percentarecarriedoutunder
safeconditions.Morethan20millioninducedabortions
eachyearareperformedbypeoplelackingthenecessary
skillsorinanenvironmentlackingtheminimalmedical
standards,orboth.
Around8%ofmaternaldeathsoccurasaresultof
prolongedorobstructedlabour.Otherdirectcausesinclu
ectopicpregnancies,embolismanddeathsrelatedto
interventions.Around20percentofmaternaldeathsaredue
toindirectcauses,thatis,theresultofpre-existingdiseasesor
diseasethatdevelopedduringpregnancy,whicharenotdue
todirectobstetriccausebutareaggravatedbythe
physiologicaleffectofpregnancy.Oneofthemostsignificant
isanaemia,whichcancausedeath.Maternalanaemiaaffects
abouthalfofallpregnantwomen.Pregnantadolescentsare
morepronetoanaemiathanolderwomen,andtheyoften
receivelesscare.Infectiousdiseasessuchasmalaria,and
intestinalparasitescanexacerbateanaemia,ascanpoor
qualitydietallofwhichheightenvulnerabilitytomaternal
death.Severeanaemiacontributestotheriskofdeathin
casesofhaemorrhage.Otherimportantcausesofindirect
deatharehepatitis,cardiovasculardiseases,diseasesofthe
endocrineandmetabolicsystemandinfectionssuchas
tuberculosis,malariaandincreasinglyHIV/AIDS(73).Each
year,approximately50millionwomenlivinginmalaria-
endemiccountriesthroughouttheworldbecomepregnant.
Around10,000ofthesewomendieasaresultofmalaria(74).
Puerperalinfections,oftentheconsequenceofpoor
hygieneduringdelivery,oruntreatedreproductivetract
infectionsaccountforabout15%ofmaternalmortality.
Suchinfectionscanbeeasilyprevented.Hypertensive
disordersofpregnancy,particularlyeclampsia(convulsions),
Tesultinabout13%ofallmaternaldeaths.Theycanbe
preventedthroughcarefulmonitoringduringpregnancyand
Severebleeding
Indirectcauses 25%
20%
Infection15%
8%
12%
13%
8%
Otherdirect
Eclampsia
causes
UnsafeabortionObstructedlabour
Socialcorrelates
irect
causes
includingforexample:ana
naemia,
malaria,
heartdiseases
Anumberofsocialfactorsinfluencematernalmortality.
Theimportantonesare(a)Women'sage:Theoptimal
child-bearingyearsarebetweentheagesof20and30years.
Thefurtherawayfromthisagerange,thegreatertherisks
ofawomandyingfrompregnancyandchildbirth.
er
ditectcauses
including,forexample:ectopic
ancy,embolism,anaesthesia-relate
FIG.10
Causesofmaternaldeathsworldwide

145. 644 PREVENTIVEMEDICINE:
INSIETRICS.ADIAIRICS
ANE)CiRIATERICS
(6)Birthinterval:Shortbirthintervalsareassoclaledwilh
an
increasedriskofmaternalmortality.(c)Parlty:High
paritycontributestohighmaternalmortality.
Notonlyarethescthreevariablesinterrelated,butthere
arealsootherfactorswhichareinvolved,e.g..economic
Circumstances,culturalpracticesandbeliefs,nutrilional
status,
environmentalconditionsandviolenceagainstwomen.Thesocialfactorsoftenprecedethemedicalcauses5
andmakepregnancyandchild-birthariskyventure.
Ellminaleallharmfulpracticesandalldiscriminae
andviolenceagainstwomenandgirls
Achieveuniversalandequitableaccesstosafea
affordabledrinkingwater,andtoadea
quate
ation
sanitationandhygiene
Enhancescientificresearch,upgradetechnolon
capabilitiesandencourageinnovation
-Providelegalidentityforall,including
birth
registration
Enhancetheglobalpartnershipfor
sustainable
development,GlobalStrategyforWomen's,Children'saud
Adolescent'sHealth2016-2030
INDIA
TheGlobalStrategyforWomen's,Children'sand
Adolescent'sHealth,2016-2030waslaunchedintheyear
2015withavisiontohavebytheyear2030,a"worldin
whicheverywoman,childandadolescentineverysetting
realizetheirrightstophysicalandmentalhealthandwell-
being,hassocialandeconomicopportunities,andisableto
participatefullyinshapingprosperousandsustainable
SOciety(75).Thestrategyisaroadmapforthepost-z015
agendaasdescribedbytheSustainableDevelopmentGoals
andseekstoendallpreventabledeathsofwomen,children
andadolescentsandcreateanenvironmentinwhichthese
groupsnotonlysurvive,butthrive,andseetheir
environments,healthandwellbeingtransformed.Theglobal
strategygoalsofSURVIVE,THRIVEandTRANSFORM and
thetargetstobeachievedby2030areasfollows(75):
Despitesignificantimprovementsinmaternalhealthover
thelastdecadeorso,whichisevidentinthereductions
in
maternalmortalityinthecountry,anestimated44.000
motherscontinuetodieeveryyearduetocausesrelatedto
pregnancy,childbirthand
thepostpartumperiod.The
majormedicalcausesotthesedeathsarehaemorrhage
sepsis,abortion,hypertensivedisorders,obstructedlabor
andothercausesincludinganaemia.Ahost
of
socio
economic-culturaldeterminantslikeilliteracy,lowsocio-
economicstatus,earlyageofmarriage,lowlevelofwomen's
empowerment,traditionalpreferenceforhomedeliveries
andotherfactorscontributetothedelaysleadingtothese
deaths.
Fromyear2000onwards,SRS(Centralregistration
system)includedanewmethodcalledthe"RHIME"
or
Representative,Re-sampled,RoutineHouseholdInterview
ofMortalitywithMedicalEvaluation.Thisisanenhanced
formof"verbalautopsy"whichisthekeyfeatureofa
prospectivestudyof
1milliondeathswithintheSRS.RHIME
includerandom
SURVIVE
Endpreventabledeaths
Reduceglobalmaternalmortalitytolessthan70per
100,000livebirths
re-samplingof
,
field-workbyanReducenewbornmortalitytoatleastaslowas12
per1000livebirthsineverycountry
Reduceunder-5mortalitytoatleastaslowas25per
1000livebirthsineverycountry
EndepidemicsofHIV,tuberculosis,malaria,neglected
tropicaldiseasesandothercommunicablediseases
Reducebyonethirdprematuremortalityfromnon-
communicablediseasesandpromotementalhealth
andwell-being
independentteamformaintainingqualityofdata.For
comparabilitywithWHOestimatesforIndiaandforother
countries,theWHO'sGlobalBurdenofDisease"
categorizatonofmaternaldeathshavebeenused,which
includesvariouscategorieswiththeirICD-10codessuch
as
haemorrhage,sepsis,hypertensivedisorder,obstructed
labour,abortion,andotherconditions.
1
TheSRSreporthasbeengroupedintothreecategories
(a)EAGstatesofBiharandJharkhand,MadhyaPradesh
andChhattisgarh,Odisha,Rajasthan,UttarPradeshand
UttaranchalandAssam.Thesestateshavehighmortalit
indicators;(b)Thiscategoryincludessouthernstateso
AndhraPradesh,Karnataka,KeralaandTamilNadu.Thes
stateshavecomparativelybetterhealthindicators;(c)Th
remainingstateshavebeenclassifiedasothers(76).
THRIVE
Ensurehealthandwell-being
Endallformsofmalnutrition,andaddressthe
nutritionalneedsofadolescentgirls,pregnantand
lactatingwomenandchildren
Ensureuniversalaccesstosexualandreproductive
health-careservices(includingforfamilyplanning)
andrights
Ensurethatallgirlsandboyshaveaccesstogood
qualityearlychildhooddevelopment
Substantiallyreducepollution-relateddeathsand
illnesses
Table14showslivebirths,maternaldeaths,materr
mortalityratioinIndiabystatesduring2016-2018,spec
surveyofdeathsusingRHIME.Duringthisperiod
lifetimeriskofmaternaldeathofwomenintheagegrc
15-49hasbeenreportedtobe0.3percent.This
substantiallyhigherforwomeninthecategoryEAGst
andAssam(0.5percent)ascomparedtowomenin
categorysouthern(0.1percent)orinthe"other"st
(0.2percent).
Achieveuniversalhealthcoverageincluding
financialriskprotectionandaccesstoquality
essentialservices,medicinesandvaccinest
Indiaisamongthosecountrieswhichhavea
maternalmortalityratio.Accordingtotheestimatesthe
hasreducedfrom167perlakhlivebirthsin2011-
113perlakhlivebirthsin2016-18.StatesofK
Maharashtra,AndhraPradesh,GujaratandTamilNadt
alreadyachievedthegoalofaMMRof100perlak
births.InEAGandAssamcategoryofstates,MMRis
161perlakhlivebirths,withAssamontop(215
TRANSFORM
Expandenablingenvironment
Eradicateextremepovertystrt.
Ensurethatallgirlsandboyscompletefree,
equitableandgoodqualityprimaryandsecondary
education

146. 645
INDICATORSOF
MCH
CARE
TABLE14 CauseS
e
major
causesof
maternal
mortality
according
tothe
2001-2003SRSsurveyarehaemoont)
obstructed
sepsis(11percent),hypen(8per
cenot
only
Maternalmortalityratio
(MMR)
nal
mortalityrateandlitetimerisk;India
EAGand
Assam,outh
andotherstates,2016-2018
aoour(6
percent),
abortion
(8per
cent)and
otner
Conditions(34percent).
Anaemia
(19
percent
eading
causeofdeathbutalsoan
aggravating
tactorin
aemorrhage,
sepsisand
toxaemia.
Illegal
abortions
arealso
Oe
orthe
leading
causesof
maternal
death.Thatthis
shourd
ninue
despite
MTP
facilitiespointstotheneedfor
wider
disseminationof
informationabout
these
facilities.1nau
aOordonsalsopointtoalarge
unmetneedfor
contraceptives
ds
Witheach
pregnancythe
womanfaces
increased
risk
O
eath.
The
percentage
distributionof
causesof
materna
deaths
duringtheyear
2001-2003areasshown
inFig
MMR 95%CIMaternalLifetime
mortality
tndia
and
major
states
risk
rate
113(103-123) 7.3 0.5%
215(133-297)
149(104-194)
(20-123)
173(126-221)
(69-249)
(96-205)
164(112-215)
197(152-241)17.8
India
Total 14.0 0.5%
15.1 0.5%
Assam
71
5.6
Bihar
Jharkhand
Madhya
Pradesh
Chhatisgarh
Odisha
Rajasthan
Utar
Pradesh
Utarakhand
0.2%
15.9
12.1
0.6%
159
0.4%
0.3%
150
7
14.5 0.5% Other
conditions
34%0.6%
99
(49-150) 6.4 0.2%
EAGand
Assam
Subtotal
161
65
(143-180)13.2 0.5%
(26-104)
(16-110)
(53-131)
(10-77)
(29-92)
0.1%
0.1%
0.2%
3.6
Andhra
Pradesh
Telangana
0
Abortion
8%63
3.6
92
4.9
Karnataka
43
2.1 0.1%
Kerala
Tamil
Nadu
60
3. 0.1%
Obstructed
(50-84)
labour
5%
Haemorrhage
38%
67
3.6 0.1%
South
Subtotal
Subtotal
5.1(41-109)
(43-139)
46
(19-73)
(56-202)
(59-137)
75
0.2%
Hypertensive
disorders
5%Gujarat
Haryana
Maharashtra
Punjab
West
Bengal
Other
states
Or
7.0
2.6
7.0
5.0
4.5
0.2%
0.1%
0.2%
0.2%
0.2%
91
Sepsis
11%
ed
129
98
FIG.11
ME 85
(62-108)
Majorcausesof
maternaldeathsinIndia
(2003)
Fo
83
(68-97)
4.7
0.2% (Figuresmaynotaddto100dueto
round-off)
Other
Subtotal
Mer
Source:(77)
Source:(76) The
determinantsof
maternal
mortalityinIndiaareas
listedinTable16.
UttarPradesh(197),
Rajasthan(164),Odisha(150),Madhya
Pradesh(173)closely
following.Assam,
MadhyaPradesh
and
Rajasthanhaveshownan
accelerationin
reductionin
lastthreeyears(76).
cted
TABLE16
Determinantsof
maternal
mortalityinIndia
Theage
distributionofmaternaland
non-maternal
deathsfromthe
2016-2018
SpecialSurveyof
Deathsare
giveninTable15.Itshowsthat
morethan
two-thirdsofthe
maternaldeathsareofwomeninagegroup20-34
years.In
contrast,non-maternaldeathsaremoreevenly
distributed
overthe
reproductiveagespanof15-49
years.
Medicalcauses
Socialfactors
and
ality
Obstetric
causes:
Ageatchildbirth
Parity
Toxaemiasof
pregnancy
Haemorrhage
Infection
Obstructedlabour
Unsafeabortion
Tooclose
pregnancies
Familysize
TABLE15
Malnutrition
Age
distributionofmaternaland
non-maternaldeaths,
India,2016-18
Poverty
ecid
Illiteracy
gnoranceand
prejudices
Lackofmaternity
services
the
Maternaldeaths
Non-maternaideaths
OUP
AgegroupsProportion
95%CI
Proportion
95%CI Shortageofhealthmanpower
Deliverybyuntraineddais
Poor
environmentalsanitation
Poor
communicationsand
Non-obstetric
causes:
Anaemia(9-10)
(11-12)
(12-13)
(12-14)
(13-15)
(17-19)
(21-23)
stat
15-19
9%
(3-7)
(29-37)
(28-37)
(13-20)
(5-9)
(2-5)
(0-3)
5%
ne
Associateddiseases,e.g
cardiac,renal,hepatic
metabolicand
infectious20-24 33%
11%
12%
25-29
30-34
32%
13%
14%
transport
facilities
Socialcustoms,
etcC.
17%
Malignancy
35-39
40-44
45-49
7%
Accidents
18%
22%
4% Newer
approachessuchas"riskapproachandprimary
healthcarearestepsintherightdirectiontoreducematernal
mortalityand
morbidity.Despitebestantenatalcare,some
womenmaydevelop
compicationswithoutwarningsigns
1%
15-49 100%
100%
guresmaynotaddto100dueto
round-ofi)
Fig
Source(76)

147. 647
MORTRLITY IN
INFANCYAND
CHIL.DHOCD
ecauseoftheabove
difficulties
WHOhas
recommended
nal
withinanycountrytheterm
"stillbirthbeappied
toa
TOeusborndead,and
weighingover500g-theirtn
gnt
most
frequentlyassociatedwitha
gestationperioa
o
weeks.
Butfor
internationai
comparison,
however,tney
uggestedaboundaryof1000gor
more.which
ismore
tequently
associatedwithagestation
periodof28weeks.
YININFANCYANDCHILD
DHOODMORTALITY
esaregoodindicatorStomeasurethelevelof
Mortaithcaseindillerentcounries.Theyalsohelp
th3the
overallsOCo-cconomicdevelopmentofa
in5 cotelatewellwithtertaincconomicvariables
cNPMedicalandsoCialrogresshavesubstantially
uted
mortalityin
childhood
ias
becotne
custotnatryfoconsidermortalityinand
STILLBIRTHRATE
infancyna
nummberoftimepetiodsconvenient
a
fom
boththe
analyticaandprugiammaficpointofviewas
he
most
widespreaduseofthetermis."deathofafoetus
weighing1000g(thisis
equivalentto28
weeksof
gestation)
oiore
occurringduringoneyearinevery1000totalbirtis
UVebirthsplus
stillbirths).Stillbirthrateisgivenbythe
formuia
a.
pcrinatal
perjiod
Foetaldeathsweighingover
100%0gatbirth
duringtheyear
carly
neoiatalperiod
x1000
late
neoatal
period S:ilbth
Totalive
stillbirthsweighingover1000gatbirth
dutingtheyear
d
neonataiperiod
post
neonatal
pericod
t2safrequentoccurrenceinthe
developingcountries.its
preventign
involvesthedetectionand
treatmentof
inifectiou:patholoyinthecouise
ofpregnancyaswellasof
high
incompaibility,diabetesandprematue
ruptureofthe
TiEmbtane.Somecausesaredifficuitorimpossibleto
diminate.tiucha*multinlepregnancies.cordanomalivs,
foetalmalfotmations,piacentaanomalies
Ttheseateas
tllustratedinlig12
OETAL.DEAT1 Foetaldeathideathrior
fo
1he
conypletecAJLEIsiCa)Exlactian
tromiltmotherof
podurtoceptiM).1
ctneothedurationof
egriate:thedeathdicsled
bytheiacthafaffench
wparationtheortusdacttofteaihehowanyofhet
vudeneeoflife.suhteatigoftheheaf.pultioti
te
umbilcalcond,oúefunitcshovethentovolintary
maseies178Defucd\eoulydeathafier
fthe209h
t
wwekofgertation
{thedefinationflengthofgetafion
varientwtweencnuntrie
Rh
bloodpressure3ndits
conplication5.
Aptimately25millionbatrieswerestilborninthe
year201
wotkdw3cde{79)inIndia.theSRSestimates
tor
theye2018fothewholecouniywasnlout5prT0U0
silalifh
{5fotheualand
7fottheurbanareas).
Amongiheiggerstate.
thiehighestievelofstilibirthshas
teenefitmated
forOdisha(10).Table18showsthe
8tatewisebreskupoffillbisthtateSomeobrCTVETSHiaveeme8d
hevie'wthafvifal
sietstucalvepotaaieiessreliabieonfoctaldeaithaoccuning
a29-27werkthiauN
tthmsesccumngalfer28compicted
wecka,andhavepreierneito2lyze
1hedalaPaateiy
Aor
he19
4rlervals..Stillluhsaleiiomteponed
TABLE18
Remats)tlityratesaodtilBirdhratenbyredencd,
esinatnlmetalitytne
Totalutlrbat
TotalRuralUrban
Slbirthtate
Jndisand
biggerstatesUls
Intanti0italit
India
AndhraPadesh
Asa
Biha
Kitattisgat
Dethi
Posjneonalsldeatt
2
22
2
2 14
3
19 23
uar
1Haryana
4imachalPradesh6
3anu&
Kashmir13
Jharkhand
KaTsataka
Kerala
MadityaPradest
Maharashtra
Odisha
Punjab
Rajasthan
TamilNadu
Telangan
UtarPradesh
Utarakhand
WestBengal
Neonalidenth
21 23
17 11
Lateeonalal
death
10
18 20
Larly
Nanatal
dent
8 22 10
32
5 2
23 10
otnatal
death 28
11
15
28
18 10
2
30 18
3 3
24 24
kBirth7Dy
esatio
1Year
25 8
28Days
17 17
Based
unthreeyearperiod2016-18)
FIG.12
Source(69)
Mortaityinandaroundiniancy

148. 649
NEONATALMORTAIITYRATE
rtality
ofallperinataldeathsoccuramong
birthweight.Thecausesinvolve
Theneonatalmortalityrateistabulated
assofperinatalmort
ut
two-thirds
witnmplicationsinthemotherduringpregnancy
Numberofdeathsofchildrenunder
28daysofageinayear
withless
trhan25
abour,.
theplacenta
orinthefoetusorheonate.
X1000
r
mor
nti
Totallivebirthsinthesameyear
::ThemaincausesotdeathareintrauterineCausesofneonatalmortality
lowbirthweight,birthtrauma,and
he
maincausesofneonataldeathgloballyareasshown
inig13.
Maina
birtn
or
neonatalinfections.Ihevariouscausesof
tenin
atal
mortality
mayoegroupedasbelow:
Pretermbirth
complications
35%J
Antenatal
causes
Maternaldiseases:hypertension,cardiovascular
diseases,
diabetes,tuberculosis,anaemia
Pelvicdiseases:uterinemyomas,endometriosis,
Intrapartum-related
complications
24%
Diarrhoea
1%
ovarian
tumours
131Anatomicaldelects uterineanomalies,
incompetentcervix
141Endocrineimbalanceandinadequateuterine
Tetanus
1%
preparation
(5)Bloodincompatibilities
(6)
Malnutrition
(7)Toxaemiasofpregnancy
(8)Antepartumhaemorrhages
(9)Congenitaldefects
(10)Advancedmaternalage
Other
7%
Sepsis
15%
Congenital
abnormalities
11%
Pneumonia
6%
G}
Intranatalcauses
(1)Birthinjuries
(2)Asphyxia
(3)Prolongedefforttime
(4)Obstetriccomplications
FIG.13
Globaldistributionofneonataldeathsbycause,20188
Source
:(83)
Nowomanshoulddiegivinglife.Norshouldanymother
endurepregnancyandchildbirth,onlytogothroughthe
agonyofhavingherchildborndeadorwatchingthebaby
dieminutesafterbirth.Yetforcountlesswomenaroundthe
worldthisscenarioremainsatragicreality.Thefirst28days
oflifetheneonatalperiod,isthemastvulnerabletimefor
achild'ssurvival.Inordertocontinuetoaccelerateprogress
inunder-fivemortality,focussingonnewbornsiscritical.
Postnatalcauses
(1)Prematurity
2)Respiratorydistresssyndrome
3)Respiratoryandalimentaryiníections
(4)
Congenitalanomalies
)Unknowncauses
Neonatalmortalityisameasureofintensitywithwhich
"endogenousfactors"(e.g.,lowbithweight,birthinjuries)
affectinfantlife.Theneonatalmortalityisdirectlyrelatedto
thebirthweightandgestationalage.Intrapartumrelated
complications,lowbirthweightandpretermbirthisacausal
factorin60percentofneonatedeaths.
insomecases;thecausesarenotclinicallyascertainable.
eTventionsforthereductionofperinatalmortality
Measurestoreduceperinatalmortalityratesareessenia
deceleratethedecliningtrendinneonataland
inant
altyrates.Forfurtherdetails,refertolable21.
Prematurityandcongenitalanomaliesaccountforabout
60percentofnewborndeaths,andtheseoftenoccurinthe
firstweekoflife.Afurtherquarterofneonataldeathsare
attributabletoasphyxia
-
alsomainlyinthefirstweekoflife.
Inthelateneonatalperiod,thatis,afterthefirstweek,
deathsatributableto_intection(includingdiarrhoeaand
tetanus)predominate.Theimportanceoftetanusasacause
ofneonataldeath,however,hasdiminishedsharplydueto
intensifiedimmunizationefforts.
Neonatalmortalityratesofbablesborntomotherswith
noeducationarenearlytwiceashighasthoseofbabies
borntomotherswithsecondaryeducationorhigher.The
family'swealthandrural/urbanresidencealsoremain
powerfuldeterminantofinequitiesinneonatalmortality.
Endingchildmarriage,reducingadolescentpregnancyand
extendingbirthintervalsarecrucialtoreducingtheriskof
mationalcertificateofperinataldeath
Internaonal
comparability,the9th(1975)Revision
eath,Th aspecialcertificateofcauseofperinatal
bulaCD
hasalsoalistof100causes(the"P"list)for
eCommend
uOnofperinatalmorbidityandmortalny
o
rnational
SiticationofDiseases(ICD-9)
dention
ofperinatalmortality
page656
underPreventive&SocialMeasures.
NEONATALMORTALITYRATE
erCommen
aredeathsoccurringduringtheneonatal
irth.Nong
atbirthandending28completedaays
Veriod,
S
ina
oatal
mortalityrateisthenumberofneonata
newbornmortality.
yearper1000livebirthsinthatyear.

149. 650 REVENTIVE
MEDICINEINOBSTETRICs,PAEDATRICSANDGERIATRIC
Directcausesofnewborndeathvaryfromregionto
region.Ingeneral,theproportionsofdeathsattributedto
prematurityandcongenitaldisordersincreaseasthe
neonatalmortalityratedecreases,whiletheproportions
caused
byinfections,asphyxia,diarrhoeaandtetanus
declineascareimproves.Patternsoflowbirthweightvary
considerablybetweencountries.Babieswithalowbirth
weightareespeciallyvulnerabletothehazardsofthefirst
hoursanddaysoflife.particularlyiftheyarepremature.
Majorityoflow-birth-weightbabiesarenotactually
prematurebuthavesufferedfrominuterogrowthrestriction,
usuallybecauseofthemother'spoorhealth.Thesebabies
tooareatincreasedriskofdeath.
40
9in
urba
rtrively
hi
20
able
2O
10
pear2
tonal
Under
Children
tre
DIgge
ChildrenChildrenChildrenCh
Neo
natalThemaincausesofneonatalmortalityareintrinsically
linkedtothehealthofthemotherandthecareshereceives
before,duringandimmediatelyaftergivingbirth.Asphyxia
andbirthinjuriesusuallyTesultfrompoorlymanagedlabour
anddelivery,andlackofaccesstoobstetricservices.Many
neonatalinfections,suchastetanusandcongenitalsyphilis,
canbe
preventedbycareduringpregnancyandchildbirth.
Inadequatecalorieormicronutrientintakealsoresultsin
poorerpregnancyoutcomes.Ithasbeenarguedthatnearly
threequartersofallneonataldeathscouldbepreventedif
women
wereadequatelynourishedandreceivedappropriate
careduringpregnancy,childbirthandinthepostnatalperiod.
aged
1-4
aged
10-1
aged
1-11
aged tive
aged
5-14 zTonal
44
months yearsyears years
ears
Mortalityrates
FIG.14
Globalmortalityratesbyage,2018
Odisha
Source
:(83)
Sub-SaharanAfricaistentimesmorelikelytodieinthefirst
monththanachildborninhigh-incomecountry(83).
NeO
India
However,neonatalmortalityisthemostdifficultpartof
infantmortalitytoalter,becauseoftheendogenousfactors
whicharenotsensitivetoimprovemenisinenvironmental
conditions.Neonatalmortalityisgreaterinboysthroughout
theworld,becausenewbornboysarebiologicallymore
fragilethangirls.
InIndiatheSRSestimatesfortheyear2018wasabout
18per1000livebirths,inearly-neonatalperiod(0-7days),
withabout20forruralareasand10forurbanareas.Table
19showstheearlyneonatalmortalityrateandpercentage
shareofearlyneonatalmortalitytointantdeathsinthe
countryandthemajorstates.Amongthebiggerstates,
TABLE19
Incidence
Earlyneonatalmortalityratesandpercentageshareof
earlyneonataldeathstoinfantdeathsbyresidence
Indiaandbiggerstates/UTs,2018
About2.5millionnewbornsdiedbeforetheyare4weeks
oldandhalfofthemdiedintheirfirst24hoursintheyear
2018.98percentofthesedeathsoccurindeveloping
countries.
Theglobalnumberofneonataldeathsdeclinedfrom
5.0millionin1990to2.5milionin2018-7,000deaths
everydayin2018,comparedto14,000in1990.Neonatal
deathsaccountedforabout47percentofallunder-fivve
deathsin2018,increasingfrom40percentin1990due
tofasterglobaldeclineinmortalityamongchildrenaged
1-59months,thanintheirfirstmonthoflife.Basedona
recentsystematicreview,aboutathirdofallneonataldeaths
occuronthedayofbirthandclosetothreequartersdiein
thefirstweekoflife.Thesefindingssuggestthatfocusingon
thecríticalperiodbeforeandimmediatelyfollowingbirthis
essentialtosavingmorenewbornlives(83).
Earlyneonatal
mortalityrate
Percentageofearly
neonataldeathsto
infantdeaths
Indiaand
biggerstates/UTs
TotalRuralUrbanTotalRuralUrban
India 18 20 1054.656.944.9
AndhraPradesh 15 19 751.757.131.9
Assam92
15 16 37.237.2 37.5
61.863.547.3
19 54.554.455.5
8
Bihar 20 20 14
22 23Chhatfisgarh
Delhi 9 4 965.750.066.0
Gujarat
Haryana
15 18 952.555.245.7
15 17 1150.752.745.4
HimachalPradesh*10 10 650.951.144.9
Jammu&Kashmir12 13 53.455.246.8
Themortalityratecomparisonforchildrenunder15
yearsofageisasshowninFig.14.
Jharkhand 17 19 1056.560.139.1
Karnataka 12 16 54.262.735.7
In2018,theneonatalmortalityratewasestimatedtobe
at18deathsper100
dyingafterthefirstmonth,inpost-neonatalperiodwas
11per1000,andprobabilityofdyingafterreaching
1year
ofageandbeforereaching5yearsofagewasat10per
1000livebirths.
Kerala 5 464.756.579.5
vebirthsglobally.Theprobabilityof MadhyaPradesh
Maharashtra
26 27 1952.853.051.8
10 52.758.6
1659.960.7
14 6 40.1
Odisha
Punjab
Rajasthan
TamilNadu
24 25 53.3
9 9 943.240.647.4
20 23 55.7
47.957.2
1254.2 46.5
7 10 4 35.7
Theburdenofneonatalmortalityisunevenacross
egions.Somecountrieshaverelativelyhighneonatal
ortalitygiventheirlevelofunder-fivemortality.Mostof
esecountriesareinSouthernAsia.Sub-SaharanAfrica
adthehighestneonatalmortalityratein2018,at28deaths
er1000livebirths,followedbyCentralandSouthernAsia
ith25deathsper1000livebirths.Achildbornin
Telangana
UttarPradesh
Uttarakhand
WestBengal
13 16 949.353.240.9
24 27 1556.459.243.5
61.6
53.255.744.3
17 17 1855.653.5
12 13 9
*(Basedonthreeyearperiod2016-18)
Source:(69)
rdre
e
as
be

150. 65
POST-NEONATAL
MORTALITYRATE
radesh(26),andOdisha
The
percentageofearlyneonataldeathsto
Allother
remaining
causes14%
(24)arethe Prematurity&
lowbirthweight
48.170
(5),
Madhya
Prac Injuries
0.9%
twoextrentdeaths
duringtheyear2018,atthenational
total
infant
deaths
durin
lpvel,hasbeen
4.6,
anditvarie
44.9in
urban
Diarrhoea
3.1%
from56.9inruralareasto
as.
Inmostofthestatesruralproportionis
gger
states,the
percentage
percentageof
neonadeathstoinfantdeathsfor
higherthanthe
uroanproportion.Amor
Congenital
anomalies
4%
fortotalvariedfrom37.2inrelativer
elhi.
Assam
to65.7in
Delh
Ill-defined
Table20
showsthe
neonatalmortalityrateinthecountry
orcause
andtne018,bothatthenationalandstatelevels.Atthe
thelevel,theneonatalmortalityratewas23and
nafrom14inurbanareasto2/
inruralareas.Among
MadhyaPra
rangorstatesneonatalmortalityrangesfrom35in
theradeshto5inKerala.Thepercentageofneonatal
deathsto
totalinfantdeaths
unknowwn
5%
Birthasphyxia
&birthtrauma
12.9
Sepsis
5.4%
was71.7percentatthe
Neonatal
Other
non-
Pneumonia
communicablediseases
national
level.
74
4
percentinrural
areas.Amongthebiggerstateselandvariedfrom60.1percentinurbanareas 7.1%
12
%
to
FIG.15
Odisha
(79.4)
registeredthehighestpercentageofneonatal
CausesofneonataldeathsinIndia,2017
deathstointan
deaths,andthelowestwasinAssam(51.4).
TABLE20
Source:(84)
Neonatalmortalityratesand
percentageshareofneonatal
deathstoinfantdeathsbyresidence,
Indiaandbiggerstates,2018
centofthecountry'stotalannuallivebirths)beingbornwith
abirthweightlessthan2500
grams.Ofthese7.5
million
babies,about60percentarebornattermafterfoetal
growth
retardation,whiletheremaining40percentareborn
preterm,constitutingonefourthofglobalburdenofpreterm
births.Pretermbabiesinadditiontobeingatahigherriskof
neonatal
mortality,areatanincreasedriskof
post-neonatal
mortality,stunting,and
long-term
neuro-developmental
impairmentduringchildhood(80).
Percentageof
neonataldeathsto
infantdeaths
Neonatal
Indiaand
bigger
states/UTs
mortalityrate
TotalRuralUrbanTotalRuralUrban
71.774.460.1
46.0
14
India
AndhraPradesh
Assam
Bihar
23
21
21
27
25
22
1070.877.5
51.451.0
60.33
66.3
12
Interventionsforthereductionofneonatal
mortality
20
22
78.780.1
26
30
25
29
10
19
22
Measurestoreduceneonatal
mortalityratesandto
improvenewbornhealthare
enumeratedinTable21,63.8
74.4
70.171.3
Chhattisgarh
Delhi
Gujarat
Haryana
HimachalPradesh13
Jammu&Kashmir
Jharkhand
Karnataka
Kerala
MadhyaPradesh
Maharashtra
Odisha
Punjab
Rajasthan
TamilNadu
Telangana
UttarPradesh
Uttarakhand
WestBengal
8 1074.8100.0
69.274.7
75.1
24
11
55.2
2.5
65.9
POST-NEONATAL
MORTALITYRATE
1624
13 Deathsoccurring
from28daysoflifetounderoneyear
arecalled
"post-neonataldeaths".The
post-neonataldeath
rateisdefinedas"theratioof
post-neonataldeathsina
givenyeartothetotalnumberoflivebirthsinthesame
year;usuallyexpressedasarateper1000"(85).
68.468.663.4
71.7
52.6
9
17 18 1475.476.3
22
1468.071.2
70.680.249.9
79.5
16 20 10
73.169.5
71.873.4
74.2
6
63.1
55.6
72.5
59.2
35 38 23
868.4 The
post-neonatal
mortalityrateistabulatedas
13 18
Numberofdeathsofchildrenbetween
28daysandoneyearofageinagivenyear
33 2279.480.2
31
13
26
10
13
1161.262.4
29 1570.672.859.4
x1000
50.8
65.376.2
69.7
73.2
14 6
Totallivebirthsinthesameyear
14
70.168.9
21
34
19 Whereasneonatal
mortalityisdominatedbyendogenous
factors,
post-neonatalmortalityisdominatedbyexogenous
(e.g.,
environmentalandsocial)factors.Diarrhoeaand
respiratory
infectionsarethemain
causesofdeathduring
the
post-neonatalperiod.
Malnutritionisanadditional
factor,
reinforcingtheadverse
ettectsoftheinfections.Inthe
developedcountries,themaincauseofpost-neonatal
mortalityiscongenitalanomalies.Studiesshowthatpost-
neonatalmortalityincreasessteadilywithbirthorder,and
that
infantsbornintoalreadylargetamiliesrunahigherrisk
ofdeathfrominfectiousdiseases.
75.860.9
73.1
21
32
22 23
21
73.273.3
16
1272.375.859.6
Basedonthreeyearperiod2016-18)
Source:(69)
CAUSES
OFNEONATAL
DEATHSININDIA
e
majorcausesofneonataldeathsareshownin
Fig.15
S
estimatedthat40percentofallstillbirthsand
haal
deathstakeplaceduringlabourandthedayof
and
about75percentoftotalneonataldeaths
occur
the
firstweekoflife.Notablyhalfofallthematernal
catnsalsotakeplaceinthisperiod(80).
InsomeareasofSouthEastAsia(includingIndia),during
the
post-neonatalperiodgirlsdiemorefrequentlythanboys.
Thisisattributedtoneglectofthefemalechildrenintermsof
nutritionandhealthcare.
birth
India
accountsfor40percentofthe
globalburdenoflow
weightbabieswith7.5millionbabies(orabout
30per
The
SRSestimatesforpost-neonatalmortalityratein

151. 652 VENTIVE
MEDICINEIN
ORSTETRICS,
PAEDIARICS
ANDGERIATHIS
TABLE21
Priorilyareastoimproenewtion
healti
I3eforeandduringpregnaney
Delayed
child-bearing.
Well-timed,
well-spacedandwanted
pregnancies
Wellnourishedandhealhymother
Pregnancyfreeofdrugabuse,tobaccoandalcohol
Tetanusandrubella
immunization
Prevention
of
mother-to-child
transmissionofHIV
Female
education
Early
contactwithhealthsystems
including:
Birih
and
emergencypreparedness
Earlydetectionand
treatmentofmaternal
complications
Monitoringoffoetal
well-beingandtimely
interventionsforfoetal
complications
Tetanusimmunízation
Preventionand
treatmentofanaemia
Eanka
Durngpregananey
landdealan
Preventionand
treatmentofinfections(malaria,
hookworm,
syphilisandotherSTIs)
VoluntaryHIVcounsellingandtestíng,andpreventionof
mother-to-child
transmissionof
HIU
Gooddiet
Preventionofviolenceagainst
women
Fordd
Durtngandsoonafterdellvery
Safeandcleandeliverybyskilledattendant
Earlydetectionand
prompt
managementofdeliveryandfoetal
complications
Emergencyobstetriccareformaternalandfoetal
conditions
Newborn
resuscitation
Newborncareensuring
warmthand
cleanliness
Newborncord,eyeandskincare
Earlyinitiationofexclusive
breast-feeding
Earlydetectionand
treatmentof
complicationsofthenewborn
Specialcareforinfantsborntooearlyortoosmalland/or
complications
Preventionandcontrolofinfections
Preventionof
mother-to-childtransmissionofHIV
Evels
o
IS
has
There
ars
WEVeT,
ElODed
Informationand
counsellingonhomecare,dangersignsandcareseeking
Duringthefirstmonthoflife
Earlypost-natalcontact
Protection,promotionandsupportofexclusivebreastfeeding
Promptdetectionand
managementofdiseasesinnewborninfant
Immunization
Protectionofgirlchild
Source:(86)
14
indiafortheyear2018wasabout9per1000livebirthsfor
thewholecountry,and9forruralareasand9fortheurban
areas.Thestate-wisebreak-upisshowninTable22.
INFANT
MORTALITYRATE
Infantmortalityrate
(IMR)isdefinedas"theratioof
infantdeaths
registeredinagivenyeartothetotalnumber
oflivebirthsregisteredinthesameyear;usually
expressed
asarateper1000livebirths"(87).Itisgivenbythe
formula
:
TABLE22
SRSestimatesofpostneonatalmortalityinIndia,
20188
Post-neonatalmortalityrate
RuralState
Total Urban
Numberofdeathsofchildren
AndhraPradesh
9
11
lessthan
1yearofageinayear
IMR=
x1000
Assam
20
8 22 Numberoflivebirthsinthesameyear
Bihar
10
6
13
Chhattisgarh
Gujarat
Haryana
HimachalPradesh
Jharkhand
Karnataka
12
IMRisuniversallyregardednotonlyasamostimportant
indicatorofthehealthstatusofacommunitybutalsoof
theleveloflivingofpeopleingeneral,and
effectiveness
ofMCHservicesinparticular.Infantmortalityisgivena
separatetreatmentby
demographersbecause
:(a)infant
mortalityisthelargestsing
(b)deathsatthisagearedueto
apeculiarsetofdiseases
and
conditionstowhichtheadultpopulationislessexposed
orlessvulnerable;(c)infantmortalityis
affected
rathe-
quicklyand
directlybyspecifichealth
programme
andhencemaychangemorerapidlythanthegeneral
deats
rate.
9
10
12
10
age-categoryof
mortality;
3
14Kerala
MadhyaPradesh
Maharashtra
Odisha
Punjab
Rajasthan
TamilNadu
11
11
5
6
12
14
11
UttarPradesh
WestBengal
India
6
8
5
International
comparisons
Duringthepastdecades,therehasbeena
steadydec
ininfant
mortality(Table23)
Dource:(69)

152. INFANT
MORTALITY
RATE
qualityoflife),withmedical
services
playing
secondary
role.
Ontheotherhand,inmostofthe
developing
countries,this
patternhasbeen
almost
turned
upside
down.That
is,
g
TABLE23
disease,
mmunization,
antibioticsand
insecticides)havemadethe
majorimpact,
withsocialand
economic
progresstaking
the
supportingrole
reluctanttofallbelow100per
1000
livebirths
in
many
developing
countries.
Itisnow
concededthatonlysocio-
economic
developmentcan
re-accelerate
the
progressandd
leadtofurther
significantfallininfantdeaths.
control
of
mass
(e.hfant
mortalityrateinelectedcountries(1990-2018)
1990 2018 medicalservices
Country
32
S8
18
100
Therefore,
intant
mortality
ratesare
India
25
57
Sri
Lanka
Bangladesh
Pakistan
Thailand
Myanmar
106
30
8
78
37
42
7
99
27
Indiaisstillamonghighinfant
mortalityrate
countries
82
intheyear2018).
IMRhas
declined
slowlyfrom204
during
1911-15,to129per1000livebirthsin1970and
remainedstaticataround127formany
years,andthen
declinedabit
onceagainto114in1980andcomingdownto
32intheyear2018.Despitethis
significantdecline,therates
arehighascomparedto
developed
countries
(Table23)
whicharenowmostlyintherangeof3-7per
1O00livebirths.
Indiaisavastcountrywithwidely
differing
populations.
The
all-Indiaratemasksvariationsthatexist
amongsub
groupsofthe
population.
Anexaminationofstate-wise
IMR
fortheyear2018showsavastregional
variation,with
MadhyaPradeshhaving
IMRof48and
Keralaaslowas7per
thousandlivebirthsduringtheyear2018.Amongthelarger
States
Kerala,
Maharashtra,Punjab,
TamilNadu,
West
Bengal,AndhraPradesh,
Haryana,
Karnataka,Gujarat,
Himachalpradesh,and
Jharkhandhaveachieved
IMRbelow
thenationalaverageof32.Withineachstatethereisrural
urbanvariation.
Acriticalinfantmortalitybeltrunsthrough
Odisha,MadhyaPradesh,Assam,Bihar,
Chhattisgarh,Uttar
Pradesh,and
Rajasthan;allthesestateshaveinfantmortality
ratesabovethenational
average.
Table24showsinfantmortalityratesinmajorstatesof
India.
Chima
InfantmortalityinIndia
Nepal
New
Zealand
USA
9
9
5
Japan
63
29
World
1990isthe
baselinefor
MDGs
Therearewidevariationsbetweencountriesorregionsin
the
levelsofintant
mortality.TheworldaverageofIMRfor
2018hasbeenestimatedatabout29per1000livebirths.
However,IMRvariesfrom4per1000livebirthsinthe
developedcountriesto46per1000
1livebirthsintheleast
developedcountries.1he
averageintheSouthAsian
countrieswas35per1000livebirths.
Althoughinfant
mortalitydeclined
significantly,thedropwasgreatestforthe
developedcountriesandlowestforleastdeveloped
countries.Thedevelopedworldhadamuchgreater
reductionininfantmortalitycomparedtochildmortality,
whileinthedevelopingworldthesituationwasreverse(83).
TheIMRsinindustrializedcountrieswerearound200or
evenmore,some150yearsago.Evenatthe
beginningofthe
20thcentury.USA,UK,Japan,France,etc,hadratesabove
140per1000livebirths.Within50years(1950)aspectacular
fallintheratewasobservedinalldevelopedcountries.
By
1980s,mostdevelopedcountriesachieved
IMRratesbelow
10per1000livebirths.
Demographersopinethatinmost
developedcountries,furtherdeclinein
IMRswouldbe
difticulttoachievewithoutsomerevolutionaryadvancesin
perinatology.Anyfurtherreductionininfantmortalityin
developedcountrieswilldependuponpreventingoneofits
principalcauses,namely,congenital
abnormalities.
Source:783
TABLE
224
IntantmortalityratesinmajorstatesofIndia(2018)
Total Rural Urban
Indiaandmajor
states/UTs
33
44
32
21
20
29
AndhraPradesh
41
32
41
Assam 30
Ingeneral,theinfantmortalityratesreflectthesocio-
economicdevelopmentofacountry.Deathsduringthefirst
fourweekSarelargelypreventablebygoodhealthcare.
Muchofthevariationsbetweendevelopedanddeveloping
WOrldindeathamongnewborncanbeexplainedby
anterencesinantenatalcareabout
halfofallpregnant
womenintheleastdevelopedcountrieshavenoantenatal
Care,and
7outof10babiesarebornwithoutthehelpofa
trainedbirthattendant.Theothermajorfactorsbeing
alnutritionandhighparityofthe
mother,lowbirthweight
ofthebaby,andcongenitalanomalies.
Bihar 42 35
Chhattisgarh
Delhi
13 3 13
20
25
14
3328
30
Gujarat
Haryana
HimachalPradesh
33
19 20
23 20
22
30
23
Jammu&Kashmir
2631
Jharkhand
25 20
Karnataka
57
Kerala
48 52 36
MadhyaPradesh
Maharashtra
1424
41
21
19
a 31
Thedeclineininfantmortalityhasbeen
attributedto
0improvedobstetricandperinatalcare,e.g.,
availabilityof
OXygen,foetal
iques
fortheinductionoflabour(b)improvementinthe
y
oflife,thatis,economicand
socialprogress
(C)better
oofcommunicablediseases,e.g.,
immunizationand
anddration
(d)advancesin
chemotherapy,
antibiotics
fsecticides
(e)betternutrition,e.g.,
emphasisonbreast
0
Odisha
1920
Punjab
Rajasthan
TamilNadu
41 2637
15
27
43
31
18 12monitoringduring
labour,
improved
30 21
Telangana
UttarPradesh
Uttarakhand
WestBengal
46 35
31 29
22 22 20
eding,and(f)familyplanning,e.g.,birthspacing. 32 36 23
India
e
industrialworld,thedominant
factorinthedecline
mortalitywaseconomicandsocial
progress(1.e,
Source:(69)

153. b54
TABEE26
Thereisplentyofevidencetoshowthatbettercontrolof
infantmortalityisrelatedtoawiderspreadofliteracy
(particularlyfemalehteracy)andprimaryhealthcareAlso,
thestateswiththehighestinfantmortalityarealsothestates
withthehighestfertility.Table25illustratestheimpactofthe
abovevariablesoninfantmortality
tat
12
montt
1
Drhouldie
Meonatal
movtalkt
0-4weeks
1.Lowbirthweight
andprernaturity
2.Birthinjuryandd:fficuftlabour
3Sepsis
4
Congenitalanomalies
5.Haemolyticdiseasesofnewbsorn Malnutrtiesn
6.Conditionsofplacentaandcord5Congenitaíanoinat
7Diarrhoealdiseases
8.Acuterespiratoryinkections
9.Tetanus
TABLE25
MR.fenaleHieracyrateandbirthTate
inmajorIndianStates
3Othercemnuab
iease
Birthrate
per
1000D
population
(2018)
Female
literacy
IMR 6Accidents
per1000
livebirths
(2018)
State
Tate
(2011)
TheprincipalcausesofintantmortalityinIndia
are
birthweight(57%),respiratoryintections(17%dianhe
diseases(4%),congenitalmaltormations(5%and
infection(2%).birthinjury3)andunclassifiedabou
(18%)(62).Neonataldeathsmakeamajorcontributien
infantmortality.Whereasindevelopingcountriesthe
highinfantmortalityismainlyduetolowbirthweighr,
and
thecombinedeffectsofinfection(e.gdiarrhoea.raespiratns
infections)andmalnutrition,indevelopedcountries,iti
mainlyduetocongenitalanomalies,anoxiaandhypoxia
AndhraPradesh 29 59.7 16.0
ASsam 41 67.27 21.1
Bihar 32 53.33 26.2
Chhattisgarh 41 60.59 22.5
Gujarat 28 70.7 19.7
Haryana 30 66.77 20.3
HimachalPradesh 19 76.60 15.7
Jharkhand 30 56.21 22.7
Karnataka 23 63.1 17.2
Factorsaffectinginfantmortality
Infantmortalityisduetotheinteractionofseveraifactors
incombination.Theymaybeclassifiedasbiclogicai
Kerala 91.98 13.9
MadhyaPradesh 48 60.20 24.6
Maharashtra 19 70.4 15.6
Odisha 40 .36 18.2
economicandsocialfactors.
20 71.34 14.8Punjab
Rajasthan
1.BIOLOGICALFACTORS
37 52.66 24.
(a)Birthweight
Birthweightisamajordeterminantofinfantand
perinatalmortalityandmorbidity.Babiesotlowbiuthweight
(under2.5kg)andhighbirthweight(over4kg)areat
specialrisk.Virtually,allinfantsweighinglessthan1000gat
birthsuccumb.Onemajorcauseotlowbirthweightispoor
maternalnutritionnotonlyduring
pregnancybut
even
beforethat.Ithasbeenobservedthatthemotherwho
was
adequatelynourishedduringherowngrowing-upyearshas
anexcellentchanceofdeliveringanormalsizebabyeven
it
shehastakenaninadequatedietduringher
pregnancyAn
increaseinbirthweightwouldlowertheperinataland
neonatalmortality.
TamilNadu 15 73.86 14.7
Telangana 27
16.9
UttarPradesh 43 59.26 25.6
Uttarakhand 31
16.7
WestBengal 22
71.16 15.0
Source:(88,89)
Table25showsthatKeralahasmanagedtosurpassall
theIndianstatesincertainimportantmeasuresofsocial
development.Ithasthelowestinfantmortalityrate,the
lowestbirthrateandthehighestliteracyrate.
(b)Ageofthemother
Thereisadefiniterelationshipbetweentheageofthe
motherandthefateofthechild.Infantmortalityratesare
greaterwhenthemotheriseitherveryyoung(belowtheage
of19years)orrelativelyolder(over30years).Veryyoung
mothersalsotendtobepoorerandlesseducated(91)
(c)Birthorder
Mortalitypattern
Deathsintheage-group0-1yearaccountfor
(a)Age
10.5percentofthetotaldeathsinthecountry.About71.7
percentofinfantdeathsoccurwithinthefirstmonth
(neonatalperiod)oflife.Ofthese,54.6percentmaydie
duringthefirstweekofbirth(69).Theriskofdeathisthe
greatestduringthefirst24-48hoursafterbirth.The
problemismoreacuteinruralareaswhereexpertobstetric
careisscarce.(b)Sex:Whereasinalldevelopedcountries,
maledeathratesarehigherthanfemaledeaths,inIndia,
aftertheageofonemonth(post-neonatalperiod)female
deathsareinvariablyhigherthanmaledeaths.Social
scientistshaveattributedthisphenomenontosocialfactors
unfavourabletofemalesinIndia(90).
Thelivebirthsareclassifiedaccordingtotheirorder
ot
rank.Thehighestmortalityisfoundamongtirstborn,and
thelowestamongthosebornsecond.Theriskofintants
mortalityescalatesafterthethirdbirth.Thefateofthe5ts
andlaterchildrenisalways
worsethanthefateofthe
3rc
child.Infantmortalityfromnutritionaldeficiencies
are
timeshigherforinfantsbornwithfifthorhigherbirthorde
comparedtothefirstthree.Thesedeathsoccurmostiy
post-neonatalperiod.
Medicalcausesofinfantmortality
(d)Birthspacing
Thecausesofinfantmortalityare
multifactorial.The
nedicalcausesareshowninTable26undertwo
ubdivisionsneonataland
post-neonatal
mortality.
Repeatedpregnanciesexertagreatinfluenceoninta
mortality.Theycausemalnutritionandanaemiain

154. 657
UNDER-5
MORTALITYRATE
deathrateisamoreretinedindicatoroftheLeadingcausesofdeath
Thecationinacountrythaninfantmortalityrate.
It
sociatheadverseenvironmentalhealthhazards
efilecalnutrition,poorhygiene,intectionsandaccidents),
Theleadingcausesofdeathinthe1-4yearsagegroup
areasshowninTable28.
TABLE28
d,mannomic,educationalandculturalcharacteristics
includ.
Mortalityinthisagegroupnolongerdepends
ofthe
ialhazardsandotherendogenousfactors,which
L.eadingcausesofdealhin1-4yearsayegroup
Developedcountries
Developingcountries
oflife.
AccidentsnRencauseloss
orhleduringthefirstyear
e
Congenital
anomalies
Malignant
neoplasms
Influenza
Diarrhoealdiseases
Respiratoryinfections
Malnutrition
n
hen
the
youngchila
runstnenighestriskofdying.Inthe
lopingcountries,death
inthesecondyearoflife
he
206
group1-4years,thesecondyearistheperiod
develolaccounts
for50percentofalldeathsbetween
Infectiousdiseases(C.gh
measles,whoopingcough) Pneumonia
Avearsofage.Atterthesecond
year,deathratesdecline
siyely.Theinfectiousdiseasesofchildhoodsuch
measles,whoopingcough,diphtheria,diarrhoeaand
Otherfebrilediseases
Accidentsandinjuries
Theleadingcausesofdeathin1-4yearsagegroupin
developingcountriesarediarrhoealdiseasesandrespiratory
intections,closelyfollowedbyother
communicablediseases
Suchaswhoopingcoughandmeasles.Whencombinedwith
malnutritionthesediseaseshavehighcasefatalityrates.Inthe
developedcountriesdeathsfrominfectiousdiseasesarequite
rare,whileaccidentsaretheleadingcauseofdeathtromthe
ageofoneyear.Fourgroupsofhomeaccidentshavebeen
identitied-(a)fallsfromunprotectedstairs,andbalconies
(6)suffocation(c)burnsandscalds(d)poisoning.Almostall
accidentsarepreventable.Thefactorssuchascongenital
acuterespiratoryiniectionsalnectmostlythisagegroup,and
canlea
leadtohighcase-iatalityrateinmalnourishedchildren.
Mortalityrateatages14
yearsisabout30insome
developingcountrieswhereasitislessthanoneindeveloped
countries.Thecontrastisglaring.whileonanaverage,the
IMRis10-20timeshigherindevelopingcountriesthanin
thedevelopedcountries,the
averagemortalityratebetween
theage1-4yearsis30-50timeshigher.
InIndia,fortheyear2018,14yearsagecrudedeath
ratewasestimatedtobe1.lpercentoftotaldeaths.Like
infantmortality,1-4yearagemortalityalsoshowswide
Theseconditionsalsoaffectchildrenindevelopingcountries,
buttheirrelativeimportanceisovershadowedbyinfections.state-wisevariationsasshowninTable27.Thestates
anomaliesandneoplasmsarenoteasytopreventortocure.
reportingrateshigherthanthenationalaverageareMadhya
Pradesh2.0,HimachalPradesh1.8,Haryana1.5,Assam
1.5,Bihar1.2,Odisha1.1andJharkhandwith1.1(69). UNDER-5
MORTALITYRATE
(Childmortalityrate)
Keralarecordedthelowestwith0.7percentfollowedby
UNICEFdefinesthisasthe"annualnumberofdeathsof
childrenageunder5years,expressedasarateper1000live
births."Morespecifically,itmeasurestheprobabilityof
dyingbetweenbirthandexactly5
yearsofage.UNICEF
considersthisasthebestsingleindicatorofsocial
developmentandwell-beingratherthanGNPpercapita,as
theformerreflectsincome,nutrition,healthcareandbasic
educationetc(98).Therateiscalculatedbytheformula:
TamilNaduwith0.6percent.
TABLE27
SRSestimatesforchilddeath(1-4years)and
uncler-livemortalityinmajorstatesofIndia,2018
Under-fivemortalityrate
(per1000livebirths)
crudedeathrateTotalRuralUrban
State Childdeath
(1-4years)
Numberofdeathsofchildrenless
than5yearsofageinagivenyear
AndhraPradesh 1.1 33 37
1.5
X1000
ASSam
Bihar
Chhatisgarh
Delht
Gujarat
Haryana
HimachalPradesh
Jammu&Kashmir
Jharkhand
Kamataka
Kerala
Madhya
Pradesh
Maharashtra
|Ddisha
unjab
Rajasthan
lamilNadu
elangana
Uttar
Pradesh
1.2 37 37 Childmortalityrate
Numberoflivebirthsinthesameyear
47
1.1
Aroundtheworld,remarkableprogressinchildsurvival
hasbeenmadeand
millionsofchildrenhavebettersurvival
chancesthanin1990.Theunder-5mortalityratefellto39
deathsper1000livebirthsin2018,from93in1990-a58
percentreduction.ThisisequivalenttoIin11childrendying
beforereachingage5yearsin1990,comparedto
1
in26in
2018.InmostoftheSDGregions,theunder-5mortalityrate
wasreducedbyatleasthaltsince1990.Thetatalnumberof
under-5deathsdroppedto5.3millionin2018from12.65
millionin1990.Onaverage,14,520childrendiedeveryday
in2018,ascomparedto34,000in1990(83).
Despiteprogressoverthepast2decades,millionsof
newbornsandchildrendieeveryyear,mostlyfrom
preventableortreatablecausessuch
asintectiousdiseases
andinjuries.Thesedeathsreilectthelimitedaccessof
childrenandcommunitiestobasicmedicaltreatmentof
infectiousdiseases,adequatenutrition,healthinterventions
suchasvaccination,cleanwaterandsanitation.Childrenface
wide-spreadregionalandincomedisparitiesintheirchances
ofsurvival.Sub-SaharanAfricacontinuestobetheregion
withthehighestunder-fivemortalityrateintheworld78
1.5 19
21
0.8
31
39 30
1.5 36
17
231.8
0.2
4 20
23
36
29
1.1
30 24
1.3
28
0.7
10
56 60
9
2.0
22 27
0.6
45
35
1.1
23
2
0.5
28
43
0.8
0.6
17
35
0.8
19 38
47
0.9
Uttarakhand 3
0.6
West
Bengal 1.1
Indla 36
Based
onthreeyearperiod20O16-18).
Source:
(69)

155. 658
PREVENTIVEMEDICINEINOBSTETRICS,
PAEDIATRICSANDGERIATRICS
deathsper1000livebirthsin2018.Thistranslatesto
1child
in13dyingbeforehisfifthbirthday14timeshigherthanthe
averageratioof
1
in185inhighincomecountriesand20
timeshigherthantheratioof
1in263intheregionot
AustraliaandNewZealand.In2018,about30percent
under-fivemortalityoccurredinSouthernAsia.About38per
centofalldeathsoccurinleastdevelopedcountries.The
numberotcountrieswithgenderdisparitiesinchildmortality
continuestodecline.Onanaverageboysareexpected
to
haveahigherprobabilityofdyingbeforereachingage5years
thangirls.Theestimatedunder-5mortalityratein2018was
41deathsper1000livesbirthforboysand36deathsper
1000livebirthsforgirls.In2017,anestimated2.9million
boysand2.5milliongirlsunder5yearsofagedied(83).
Causesofunderfivedeaths
Understandingthe
causesofchild
mortal
importantpublichealthinsights.Otthe5.3millprovd
childrenunder-5,thatoccurredin2018,almosteathsies
elame
pieunO
wnnets
an
th4
gether
thes
causedbyinfectiousdiseasesandconditions
such
pneumonia,diarrhoea,alaria,meningitis,tetanus,
HIU
andmeasles.Around47o
ofallunder-fivede.
deaths
oceurred
in
theneonatalperiod(withinthe
first28daysof
Ted
majorityfrompretermbirthcomplicationsand
in 1alp0x,
B
mHe
TEcent
intrap
relatedcomplications(complicationsdurinoartum.
1he
Espanded
Globally,morethanhaltoftheunder-fivedo
r
attributabletoundernutrition(99).
-five
deaths
Worldwide,theleadingcausesotdeathamongchitd.
are
Arecentanalysisshowedthatchildreninthepoorest
householdsarenearlytwicelikelytodiebeforetheageof5
asthosefromtherichest.Theriskofdeathinruralareasis
1.5timeshigherthanforchildrenintheurbanareasand
Withinurbanareaschildrenfrompoorerhouseholdtendto
havehighermortalityrates.Childrenofmotherswholack
anyeducationare2.6timesmorelikelytodiebetore
reaching5yearsage.Poorairqualityisanotherrisktactor
forchildmortality(97).
under-5yearsincludepneumonia(12%ofall
atlonal
ldren
deaths),pretermbirthcomplications(16%),diarrho
ve
under
intrapartum-relatedcomplications(11%),malaria
(59
neonatalsepsis(7.0%),meningitis(2.1%),tetanusnd
measles(2%),injury(6%)andothers(12%).Cross.e
comparisonsshowawidevariationamongcountriesi
tlnzalto/7
gS
As
1mortalitg
yNENIaDledi
renont
a8
ac
nthe
proportionsofunder-fivedeathsattributableto
causes.Suchvariationsindicatethatoptimal
program
speci
approachesforchildsurvivalwillditterfromcountr
Table29showschildmortalityrateinsomeselected
developedanddevelopingcountries.
to
country.Fig.16shows
thecausesofdeathofchildr
witely
umple
aeRW
Ad
alrnoea/
malaria
an
under-fivein2018.
e
lnteg
dren
he
Summarizingdataacrossregionsandcountriesmac.
substantialdifferencesinthedistributionofcausesofdeath
Approximately90%ofallmalariaandHIV/AIDSdeathsin
children,morethan50%ofmeaslesdeathsandabout40g
ofpneumoniaanddiarrhoealdeathsareintheAfrican
Region.Ontheotherhand,deathsfrominjuriesand
non
communicablediseasesotherthancongenitalanomalies
accountfor20-30%ofunder-fivedeathsintheregionof
theAmericasandintheEuropeanandWesternPacific
Regions(100).
TABLE29
Onder-5mortalityrateinsomeselected
countriesduring1990andmid2018
hila
nave
combins
(Per1000livebirths)
Country
e
imprcs
1990 2018
EUmos
DPalea
enyirat
India
SriLanka
126 37.0
Thailand
21 7.0
omot
37
142
9.0
Nepal
China
healin
32.0
Thesteadyimprovementinunder-fivesurvivalis
explainedbyacombinationofadvances.Theyinclude
developmentsinscienceandtechonology(torexample,oral
rehydrationsaltsthattreatdiarrhoealdehydrationand
insecticide-treatedmosquitonetstormalariaprevention),
improvedhealth-seekingbehaviours(suchaswomen's
increasinguseofantenatalcareandskilledprovidersfor
carearoundthetimeofbirth),improvedsanitationand
improvedcoverageofeffectiveinterventionstopreventor
treatthemostimportantcausesofchildmortality.Eachone
Bangladesh
Pakistan
54
144
9.0
30.0
139 69.0
UK
9 4.0
USA
11 7.0
Japan
Singapore
World
6
2.0
8 3.0
90 39.0
Source:(5)
Pneumonia12%
Pneumonia3%
Deathsamongchildren
aged1-59months(53%)
Pretermbirth Neonataldeaths
complications16% (47%)
Other12%
Intrapartum-related
events11%
Congenital4%
Intrapartum-relatedevents1%-
Pretermbirth
complications2%
Sepsis7%
Meningitis2%
AIDS1%
Other3%
Malaria5%
Injury1%
Congenital5%
Diarrhoea8%
DiarrhoeaTetanus1%Injury6%
Measles2%
0.3%
FIG.16
Global
distributionofdeathsamong
childrenunder-5bycause,2018
Ource:83)

156. M
ntofNewbornandChildhoodlllnesses(IMNCI),
Management
Separate
INTEGRATED
MANAGEMENT OF
CHILDHOODILLNESS
(1MC)
ocusn
newborn
issues;
and
for
supervisiona
ols
andidelineshavebeenproducedthat
theseareusedtotrainfieldstaff
andmonitoringpurposes.
Thenotionof
integrationhasalong
hístory,
Integration
1
Supposedtotackletheneedfor
complementarityof
different
independentservicesand
adminístrative
structures,s0
aso
oetterachieve
commongoals.
In1950s,thegoals
were
aeined
intermsofoutcome,in1960sofprOcessandin
tne
99USofeconomicimpact.
Integrationhasdiferent
meaningsatdifferentlevels.Atthepatíent
levelit
means
casemanagement.Atthepointof
deliveryitmeansthat
multiple
interventionsare
provided
through
onedelivery
channel,e.g.,wherevaccinationisusedasan
opportunityto
providevitaminAtothechild,boostíng
efficiencyand
COverage.Atthesystemlevelintegration
meansbringing
together
managementandsupport
functionofdifferentsub-
programmesand
9014,
India
NewbornAction
Plarwerelaunchedinviewto
In
the
year
2013,
RMNCH+
strategyandintheyear
mortalityratesinchildren.Newervaccineswere
the
introducedin
thenatreduoodinthenationalimmunizationschedule.Please
eferto
chapter/for
details.
The
Global
StrategyforWomen's,Children'sand
cent's
Health
(2016--2030)andthe2030agenda
-
Survive,riveandTransform.TheSDGs
contain
ambitioutargetsforhildmortalitywithSDG3.2
der5
year.ThesecludenationaltargetsofaU5MRof
Sustainable
Developmehavethreeoverarching
for
objectives
deathsofnewbornsandchildren
gekingtoend
preventable
ensuring
complimentarity
between
more
than25per1000livebirthsandneonatal
mortalityy
ate
tono
morethan12perl000livebirths(102).Target
42.whichcallsforeffortstoensurethatallgirlsandboys
haveaccesstoqualityearlychildhood
development,care
and
pre-primaryeducation;whichislikelytohaveanimpact
on
childmortality,whilealsoimprovingchildren'schances
oflongand
rewardinglives(102).
differentlevelsofcare.
IMCIisnowtheonlychildhealth
strategythataimsforimprovedintegrationatthesethree
levels
simultaneously.Morethanjustadding
more
programmestoasingledeliverychannel,ithassoughtto
transformthewaythehealthsystemlooksatthechildcare.
Mostsickchildrenpresentwithsignsand
symptoms
relatedtomorethanoneconditions.Thisoverlap
means
thatasinglediagnosismaynotbepossibleorappropriate,
andthat
treatmentmaybe
complicatedbytheneedto
combinetherapyforseveral
conditions.Surveysofthe
managementofsickchildrenatthese
facilitiesrevealthat
manychildrenarenotproperlyassessedandtreatedand
thattheirparentsarepoorlyadvised.
Providingqualitycare
tosickchildreninthese
conditionsisaserious
challenge.In
responsetothesechallenge,WHOand
UNICEFdevelopeda
strategyknownasIMCI.Thestrategycombinesimproved
managementofchildhoodillnesswithaspectsofnutrition,
immunization,andotherimportantdiseasepreventionand
healthpromotion
elements.Theobjectivesaretoreduce
deathsandthe
frequencyandseverityofillnessand
disabilityandtocontributetoimprovedgrowthand
development.
CHILD
SURVIVALINDEX
Thebasic
measureofintantandchildsurvivalisthe
Under-5mortality(numberofdeathsundertheageof
5years,per1000livebirths).Achildsurvivalrateper1000
birthscanbesimplycalculatedbysubtractingtheUnder-5
mortalityratefrom1000.Dividingthisfigurebytenshowsthe
percentageofthosewhosurvivetotheageof5years(103)
1000under-5mortalityrate
Childsurvivalrate=
10
Thefollowingtable(Table30)showsthechildsurvival
ratesofsomecountries.
TABLE30
Thestrategyincludesthreemain
components
Childsurvivalratesofsomecountriees
(1)Improvementsinthe
case-managementskillso
healthstaffthroughtheprovisionoflocally
adapted
guidelinesonIMCIandthroughactivitie
topromotetheiruse;
(2)Improvementsinthehealthsystemrequired
effective
managementofchildhoodillness;and
(3)Improvementsinfamilyandcommunitypractice
during1990and2018
Country
1990
2018
India
87.4
96.3
SriLanka
97.9
99.3
Bangladesh
85.6
97.0
Thecoreofthe
IMCIstrategyisintegrated
ca
managementofthemostcommonchildhoodproblems,wi
afocusonthe
mostimportantcausesofdeath
i.
diarrhoea,
ARI,malaria,measlesandmalnutrition.Aguid-
processofadaptation
ensuresthattheguidelines,and
learning
epidemiologywithinacountryandaretailoredtofit
needs,
resourcesandcapacityofacountry'shealthsystera
Theclinicalguidelines,whicharebasedonexpertclini
opinionand
researchresults,aredesignedfor
managementofsickchildrenagedlweekupto5ye
They
management,usingasyndromicapproachthatsupports
rational,effectiveandaffordableuseofdrugs.Theyinch
methodsforassessingsignsthatindicatesevere
disee
assessingachild'snutrition,immunization,andfeed
teaching
parentshowtocareforachildathome;counse
Nepal
85.8
96.8
Pakistan
86.1
93.1
China
94.6
99.1
UK
99.1
99.6
USA
98.4
99.3
materialsthatgowiththem,reflect
Japan
99.4
99.8
Singapore
99.2
99.7
difference
inthe
survivalratesofchildren
in
Thired
anddevelopingcountriesisagrimpointertotne
Third
World's
edforpreventive
services.
Throughbreast
promote
evidence-basedassessment
eeding,
adequate
rog
nutrition,
clean
water,
immunization
Virtmes,oralrehydrationtherapyandbirthspacing,
a
inn
revolutioninchildsurvivalcouldbeachieved.1ne
impact
1erms.
WOuldbedramaticin
humanitarianand
tertility

157. 666
PREVENTIVE
MEDCiNE19
O8STETRIS,
PAEDIATRICSAND
GERATHIC
hem.
Attentiontopostureisalsoimportant.
Childrenoften
adoptbad
postureswhilesittingandstanding.uch
tendencies,shouldbe
observedand
corrected.
Itis
increasingly
recognizedthatthemajor
degenerativediseases
ofadultshavetheirorigininpoorhealthhabitsformedearly
inlife.Cigarette
smokingisan
exampleofapublichealth
problem
2)
EnvironmentalHealth
Encouraging
youngpeopleto
takepartinhealthactivitiesandkeeptheir
environmentf
clean
isanimportant
functionofschoolhealth
services.
Visitstoobserve
communityhealth
programmes,and
evenn
better
participationin
communityaction
programnes
e.g,vaccination,
flycontrol
campaigns,
constructionof
sanitarywellsand
latrines)areexcellent
opportunities1or
health
education.(3)Familylife
:Familylifeeducafionis
being
increasingly
recognizedasapriorityinbofhdeveloped
and
developingcountries.Theschoolhealthserviceis
concernednofonlywiththe
developmentfofhealthylives
butalsowithhealthyattitudestowardshuman
reproduction.
supervision
Theserecords
willalsobeusefulin
and
evaluatingschoolhealth
programmesandprovigention
for
childres
Defects
ar
birth
ged
le
fo
Rashiria
B
rant
initta
anal
nmunity,
usefullinkbetweenthehone,schoolandthe
commng
a
School
health
programmeunder
AyushmanBharat
The
programmehasbeen
developedbased
learningand
experiencesirom
avarietyof
alohat
anid
the
itically
manage
evel
while
that
shouldbe
tackled
schools.
us
including
disat
lities
DEIC
will
ns
Once
the
cA
ouild
be
ensured
delivered
at
zero
or
national
schoolbased
interventions
preferablyonemaleand
onefemale,in
every
designatedas"Healthandwellness
Ambassadors
trainedtotransactheathpromotonanddisease
preventie
informationintheformof
interestingactivitiesfor
on
0
everyweek.Thesehealthpromotion
messageswillalsoHur
bearingonimprovinghealthpractices
inthe
countr
students
willactasHealth
andwelness
Messengers
the
society
(119).
Twoteachers
itions
wIl
be
FoVIsionof
seru
Weekly
iron
ars
or
age
will
ese
services
us
Activitiesinschool
Healtheducationinschoolsisafunctionoftheschool
teacher.Thehealthofficerandthepublichealth
nurse
health
Weekly
worker/healthassistantmayfurnishteaching
Classroom
transactions
byhealthand
wellne
zachers
materialsandadvice,buttheteacheristhekey
personinthe
presentationofthematerialtothe
children.Todothis
importantwork,theteachershouldbewellversedinhealth
education
techniques,andsincerelyinterestedintheweltare
ofthepupils.Childrentakebacktotheirparentsthehealth
instructionstheyreceiveinschools,and
evenmore
important,whentheybecomeadultstheyapplythis
knowledgetotheirownfamilies.Indeveloping
countries,
wherei-health
isamajorproblem,"everyschoolchildisa
healthworker
ambassadors
Iness
AdministrationofIFAtablets
E
STOups
ntervention
Fortnightly/Monthly
Thematic
school
assembly
Questionbox
responses
Quarterly
Thematic
AHDs
Parent
teacher
meetings
Ervnce
delia
11.Educationof
handicappedchildren
Bi-annual
Deworn
Governme
I0th
Febr
Theultimategoalistoassistthe
handicappedchildand
hisfamilysothatthechíldwillbeabletoreachhismaximum
potential,toleadasnormalalifeaspossible,tobecomeas
independentaspossible,andtobecomeaproductiveand
self-supportingmemberofthesociety.The
resourcesfor
managing
handicappedchildvaryfromcountrytocountry.
Itreguiresthecooperationofhealth,welfare,socialand
educafionalagencies.
Administrationof
dewormingday)
albendazoletablet(National
Gewormi
400mg
gOvernn
will
cor
TheHealthand
Wellness
Ambassadorswillfacilitate
linkageswithotherongoingschoolbased
programmeslike
WIFS,NDD,MHSand
RBSK;and
coordinatereferralof
students
requiringanysupportor
treatmenttothe
Adolescent
FriendlyHealthCentresandHealth&Wellness
Clinics.Foranygreater
informationthatthe
students
require,theymayalsobereferredtothe
Adolescent
friendly
healthresourcecentresatthedistrictlevel.
Mer
be
pro
quide
12.Schoolhealthrecords
Acumulativehealthrecordofeachstudentshouldbe
maintained.Suchrecordsshouldcontain(a)ldentifyingdata
name,dateofbirth,parent'snameandaddress,etc.
(b)pasthealthhistory(c)recordoffindingsofphysical
enaminationandscreening
testsandrecordofservices
provided.Thepurposeofmaintainingschoolhealthrecords
is
tohave
cumulative
informationonthehealthaspectsof
school
childreninordertogivecontinuing
intelligenthealth
Schoolhealthpromotion
activities
Thehealthpromotion
activitieswillbegivenaspecial
focus.Ageappropriatehealtheducationforthestudentswill
betakenupto
influencebehaviourandenhance
skills.The
frameworkdevelopedpaysspecialattentionto
physical,
psycho-socialand
mentalaspectsbasedonthe
developmental
stagesofthechild.Thebroad
componentsare:
Ageappropriatehealthpromotion
Primaryschool
Health.
growthand
development
Personal
safety
Nutrition
and
physicalactivíty
Hygiene
practices
Prevention
ofdiseaseslike
malaria,dengue,
TB,
worms
infestation,diarrhoeaand
vaccine
preventablediseases
Middleschool
Highschool
.Pubertyandrelatedchanges
Eyecare,oralhygiene
Preventionofsubstanceabuse
Sexual&reproductivehealth
.Violenceprevention
.Unintentionalinjury
.Road
safety
Nutrition
Bullying
prevention
.Meditationand
yoga
Internetsafetyandmedialiteracy
.Preventionof
substanceabuse
.HIV
ADS
Mentalhealth
Nutrition
Meditation
andYoga

158. HANDICAPPEDCHILDREN667
Health
screening(719
Upgradingskillsinemergencycare
riya
BalSwasthyaKaryakram(RBSK)
is
in
Rashtrtiativeaimingatearlyidentificationandearly
Achildspendsaconsiderablepartofthedayinschool,
whichmakesittheresponsibilityoftheschooltoensurethe
safetyofallchildren
in
everypossiblewayduringtheirstay
atschool.Thusstudentsandteachersshouldknowthebasis
irst
aidandshouldbeabletorespondtoemergencies.
Thereshouldbeafirstaidboxavailableineachschool.he
teachersandstudentswillbemadeawareofthevar0us
Servicesavailableineachschooltoemergencieslikethe
ambulance,firebrigade,police,closesthealthfacility,etC.
essionsofthebasicfirstaidwillbetakenupandlinkage
withlocaldisasterresponseteamwillbemade,tobuildthe
capacityofschoolteachersandchildrentorespondto
emergencies.
an
importa
rventiotbirth,Deficiencies,
Diseases,Development
hildrenfrombirthto
18
yearstocover4'D's
viz.
Detects
The0-6yearsagegroup,willbedelays
luding
disability.
Specificalcallymanaged trictEarlyIntervention
Center
DEIC)level
whilefo
nditions
for6-18yearsagegroup,
managementof
willbedonethroughexistingpublichealth
lacilitie
DEICwill
a
Oncethechild
i
actasreferralinkagetorboththeage
screenedandreferredfromschool,
gouphoensuredthatthenecessarytreatment/interventiontwould
leliveredatzerocosttothefamily.
s
Provisionofservices(119)
eeklyiron
yearsof
agewillif
aae
willfollowtheexistingguidelinesintheschools.
folicacidsupplementation
through6-19
Schoolhealthadministration
Thehealthoftheschoolchildistheresponsibilityofthe
parents,teachers,healthadministratorsandthecommunity.
Thesuccessorefficiencyofschoolhealthservicedepends
largelyoneffectivecoordinationbetweentheparticipating
agencies.Thereisnouniformpatternofschoolhealth
administration,bothhereandabroad.InEngland,school
healthserviceispartoftheEducationserviceofthecountry.
InIndia,schoolhealthserviceisadministeredbydifferent
departmentsindifferentStatestheseareusuallythe
departmentsofHealthandEducation.TheSchoolHealth
CommitteesetupbytheGovernmentofIndia,in1960
recommendedthatschoolhealthserviceshouldbean
ese
serviceswillntinuetobedeliveredthroughschool
teachers.
6-10years 10-19years
Agegroup
Intervention
dose
Tabletsof45mg
elementalironand
400megoffolicacid
Tabletsof100mg
elementalironand
500mcgoffolicacid
Weekly,throughout
theperiod
6-10yearsofage
Weekly,throughout
theperiod
10-19yearsofage
Regime
Throughteachers Throughteachers integralpartofthegeneralhealthservices.Thegeneral
healthservicesinIndiaareadministeredlargelythroughthe
primaryhealthcemtresintheruralareas,wherethebulkof
India'spopulationlives.Schoolhealthserviceis,therefore,
animportantfunctionoftheprimaryhealthcentres.
Servicedelivery
Tocombatparasiticworminfections,
Deworming
GovernmentofIndiahasdeclared10thAugustand
10thFebruaryasfixeddaystoprovideAlbendazoletabletsfor
dewormingschool-agechildren.DuringNDD,Albendazole
400mgchewabletabletswillbeadministeredtochildrenat
government,government-aided,andprivateschools.This
will
continuetofollowthecurrentNDDguidelines.
Menstrualhygienemanagement:Sanitarynapkinsmay
beprovidedintheschoolsforadolescentgirlsasperMHS
guidelines.
(a)Primaryhealthcentres
Theprimaryhealthcentresarechargedwiththe
responsibilityofadministeringschoolhealthservicewithin
theirjurisdiction.Itrequiresawhole-time,medicalofficerto
cOver5,000to6,000childrenayear.TheSchoolHealth
Committee(1961)has,therefore,recommendedthatthe
staffoftheprimaryhealthcentresshouldbeaugmentedby
additionalstaiftocarryouteffectivelytheschoolhealth
HeaithscreeningUnderRBSK,identificationof
30diseasesincludingmalnutritionandanaemiawithprogramme.
appropriatereferrals.ldentificationofchildrenwith
relractiveerrorsmaybedoneandspectaclesprovided. (b)SchoolHealthCommittees
Physical
andmentalfitnessClassesonyogaand
meditationthroughHealth&WellnessAmbassadorsmaybe
promotedonthelinesof'InternationalYogaDay'to
nculcatethehabitsofyogaandmeditationamongchildren
since
theirchildhood.
TheSchoolHealthCommittee(1961)inIndia
recommendedtheformationofschoolhealthcommitteesat
thevillagelevel,blocklevel,district1level,stateleveland
nationallevel.TheseCommitteesshouldmobilizecommunity
resourcesandmaketheschoolhealthprogrammecontinuous
andself-supporting.TheNationalSchoolHealthCouncilwill
beanadvisoryandcoordinatingbody.
Research
Provisionsmaybemadeforresearchand
sudiesonhealth,wellnessandnutritionforchildrento
a5esstheimpactoftheprogramme.
HANDICAPPEDCHILDREN
erpreventiveservicesintheformofregularage
PTiatevaccinationofchildrenthroughlocalhealthstaff
are
beingconsidered. Definitions
"Handicap"maybedefinedas"reductioninaperson's
capacitytofulilasocialroleasaconsequenceofa
impairment,inadequatetrainingfortherole,orothe
circumstances.Appliedtochildren,thetermusuallyreferst
thepresenceofanimpairmentorothercircumstancestha
arelikelytointerierewithnormalgrowthanddevelopme
orwiththecapacitytolearn"(120).
InternationalClassificationofImpairments,Disabiliti
andHandicaps(ICIDH):FirstpublishedbyWHOin198
lectronic
healthrecords
Is
envisagedtodevelopanelectronichealthrecordforeach
h
student.
Student
eening
andservice
HealthCardwill"includehealth
accessdataforeachstudent.Under
chidrothescreeningandreferralrecordsofalltheschool
lo
sch bedigitalized.Therelevantinformationrelated
Tecordenealthactivitieswillbeaddedtoexistingelectronic
Ordsmaintained
underRBSK.

159. 676
PREVENINEUMCINIIN(MSTLRAS,
PAEDIATRIGSANDGERIATHES
Strengthening thecapacity
trasler,harbouringorneceiptofachildforthepurposeof
ENploitation.Aclhilkltraltickerisanyonewhocontribulesto
nchmentofthetraflickingprocesswiththeintentto
Nploitthechild.Thisincludedthosewloplayonlyapartin
theentireprocess,suclhasrecruiters.intermediaries,
documentproviclers,Iransporters,curruptofficinls,service
provilersandunscrupulousemployers.Girlsarelralficked
disroportionatelyforcomercialsexualexploitationand
childdomestielabour.ThelLO2005GlolbalReport
estimalesthatAsiahastlhehighestnumberofchild
rattickingvictinmsfollowedbyindustrializedcountries,Latin
AmericaandCaribbean,theMiddleEastCountries(132).
communitiestocareforandrotect
chiidrorGovernment
commitment
tochit
providing
budgetarysupport
andpoliciestargetedatthemostexcludoduded
and
irrads,
children.
Ratificationandimplementation
of
gislatten,nationalandinternation
concernir
rightsandprotection.
against
chldton
Prosecutionofperpetrators
ofcrimes
acandavoidanceofcriminalizing
child
victims.
Anopendiscussionbycivilsociety
andthe.dthemesa
es
"Poverty-plus"atsource,transitanddestination:Poverty
alonedoesnotguaranteethatachildwillbetrafficked,
usualyitispovertyplusoneormanyotherriskfactorsthat
makeachildvulnerabletotraflicking.Thesecouldbeatthe
individual,household,communityorinstitutionallevel.
Somecommoncausesofvulnerabilityincludelackofbirth
TCgistration,discrimination,orphanhood,illnessinthe
family,familyabuse,conflictornaturaldisaster,travelling
aloneorthroughanon-registeredagencyorsmuggler,
inabilitytospeakthelanguage,unregulatedinformal
economy.
corruptionandalargeyouthpopulationwithlowlabour
marketabsorption.Vulnerabilityisnotstatic,itchangesover
time,anddifferentriskfactorsarepresentindifferent
contexts(132).
attitudes,prejudices,belief
and
practicesfacilitateorleadtoabuses.
the
Ensuringthatchildrenknowtheir
encouragedtoexpressthemandareaivenrskillsandinformationtoprotectthemselyo-
abuseandexploitation.
Availability
ofbasicsocialservices
toall
chitl
withoutiscrimination.
rights
children
Monitoring,transparent
reporting
and
oversicht
eabusesandexploitation.
Thekeytobuildingtheprotective
environment
isresponsibilityofmembersofthesociety,byensurine
childrenarenotexploited.Whilefamilies
andtheStatea
theprimaryresponsibilityforprotectingchildren,ongeir
andsustainedeffortsbyindividualsandorganizationsat
levels,areessentialtobreakpatternsofabuse.
UJJAWALA:"Ujjawala",acomprehensive
scheme
tocombattraffickingwaslaunchedinIndiabytheMinistryc
WomenandChildDevelopmenton4thDecember,
2007
andisbeingimplementedmainlythroughNGOs.
The
schemehasfivecomponentsotprevention,rescue
rehabilitation,reintegrationandrepatriationofvictims
traffickedforcommercialsexualexploitation.Someofthe
provisionsundertheschemeare(65):
weaklegalframeworkandenforcement,
Traffickingofchildrentakesmanydifferentforms.Some
childrenareforciblyabducted,othersaretrickedandstill
othersopttoletthemselvesbetraffickedbypromiseof
earnings,butnotsuspectingthelevelofexploitationthey
willsufferattheotherendoftherecruitingchain.Trafticking
alwaysinvolvesjourney,whetherwithinthecountryor
acrosstheinternationalborder.Therelocationtakes
childrenawayfromtheirfamilies,communitiesandsupport
net-work,leavingthemisolatedandutterlyvulnerableto
exploitation.Collectingdataaboutthesechildrenisvery
difficult.Itisestimatedthattraffickingaffectsabout
1.2millionchildreneachyear.
Thoughthetraffickingofchildrenisashadowypractice,
somedominantregionalpatternsareidentifiable.In
WestandCentralAfrica,childrenare"placed"inamarginal
positionwithinotherfamilies.Thispracticeisbeingusedto
exploitchildrenbothwithinandoutsidehome.Childrenare
alsotraffickedintoplantationsandmines,andinthose
countriesaffectedbyconflict,theyaredirectlyabductedby
militias.InEastAsiaandPacific,mosttraffickingisintochild
prostitution,thoughsomechildrenarealsorecruitedfor
industrialandagriculturalwork.InSouthAsia,trafficking
formsmostofimmensechildlabourprobleminthesub-
continent,oftenrelatedtodebtbondage.Inaddition,
significantnumberofchildrenaretraffickedforother
purposes,includingintoprostitution,carpetandgarment
factories,constructionprojectsandbegging.InEurope,
childrenaremainlytraffickedfromeasttowest,reflecting
thedemandforcheaplabourandchildprostitutioninricher
countriesofthecontinent.Childrenarealsousedas
unskilledlabourandintheentertainmentsector.
(1)Formationofcommunityvigilancegroups,adolescents
groups,awarenesscreationandpreparationofIEC
material,organizingworkshops;
(2)Safewithdrawalofvictimsfromtheplaceof
exploitation;
(3)Rehabilitationofvictimsbyprovidingthemsafeshelter,
basicamenities,medicalcare,legalaid,vocational
trainingandemployment;
(4)Re-integrationofvictimsintosociety;and
(5)Providesupporttocross-bordervictimsfortheirsafe
repatriationtothecountryoforigin.
PreventingViolenceAgainstChildren(133)
Globally,itisestimatedthatoneoutoftwochildrenage
2-17yearssuffersomeformofviolenceeach
ye=
Worldwide,closeto300millionchildrenaged2-4
yea
regularlyexperienceviolentdisciplinebytheircaregivers
thirdofstudentsaged11-15yearsworldwidehave
bE
bulliedbytheirpeersinthepastmonth,and120mill
girlsareestimatedtohavesufferedsomeformoftor
sexualcontactbeforetheageof20years.Emotic
violenceaffectsoneinthreechildrenandworldwideon-
fourchildrenliveswithamotherwhoisthevictin
Anestimated8.4millionchildrenworkunderterrible
circumstancesandareforcedintobondageorotherformsof
slavery(Fig.19).
Makingchildrensaferequirescreatingaprotective
environmentforthem.Thekeyelementsofaprotective
environmentinclude:

160. 67:7
xtnerviolence.Anestimatec40,150children
ntimate
partn
didedatefor0-17yearsoldwas1.7per100,000
verevictimsofmicideintheyear2017.The
Communitymobilization
programmes
By-standerinterventions
gotbrahal
hondtherateforboysot2.4per100,000was
Safe Reducingviolencebyaddressing
"hotspotss
Interruptingthespreadofviolence
Improvingthebuiltenvironment
Deliveredthroughhomevisit
Deliveredingroupsincomnmunity
settings
Deliveredthrough
comprehensive
poulatio
vice
girls(1.1per100,0O0population).
Thethanin environments
tic
impactontheprevalenceofviolenceagainst
their
lifetime.childrenexposedtoviolenceareat
vioursikealcohoanddrugabuse,smokingand
cOVID
pandemic andsocieliesresjponsetoithashada
childrerand
is
onsequences.
likelytohavelong-lastingnegativeParentand
caregiver
Support
dTisk
ofmentalillnessandanxietydisorders;high
incneas programmes
risk
chronicdiseasessuchascancers,diabetesand
unsa
o3ase:infectiousdiseaseslikeHIV;andsocial
educationalunderattainment,further
Incomeand
-Cashtransfers
Groupsavingandloanscombined
withgenderequity
trainingg
Micro-financecombinedwithgender
normtraining
economic
ar
ems
including strengthening
vementinviolengandcrime.Theeconomiccostsof
these
consequencesareenormous.
The
eliminationofviolenceagainstchildreniscalledfor
ceveraltargetsofthe2030AgendaforSustainable
mevelopmentGoals.speciallyin
Target16.2:"endabuse,
nloitation.trailickingandalllormsofviolenceand
torture
ochildren.
Itfocussesoninierpersonalviolencewhich
cauntsformostactsofviolenceagainstchildren,and
nrludeschildmal-treatment,bullyingandothertypesof
vOuthviolenceandintimateperson
cOvernmentscanmonitortheir
progresstowardsreaching
heSDG
overcourseof2020-2030,throughthelensof
SevenINSPIREevidence-basedstrategiesforending
Responseand
Supportservices
-Counsellingandtherapeutic
approaches
Screeningcombinedwith
interventions
in
-Treatmentprogrammesforjuvenile
offendersinthecriminaljustice
system
-Fostercareinterventionsinvolving
socialwelíareservices
violence.The
Educationand
lifeskills
Increaseenrolmentinpre-school
primaryandsecondaryschools
Establishasafeandenablingschoolviolenceagainstchildren.
environment
INSPIRE:Sevenstrategiesforendingviolence
againstchildren(133)
INSPIREisasetofsevenevidence-basedstrategiesfor
Improvechildren'sknowledgeabout
sexualabuseandhowtoprotect
themselvesagainstit
-Lifeandsocialskillstraining
-Adolescentintimatepartnerviolence
countriesandcommunitiesworkingtoeliminateviolence
againstchildren.Launchedin2016,INSPIREservesasa
technical
packageandhandbookforselecting,implementing
andmonitoringeffectivepolicies,programmesandservices
topreventandrespondtoviolenceagainstchildren.
INSPIREisanacronym,witheachletterrepresentinga
stategy:
1
fortheimplementationandenforcementoflaws;
Nfornormsandvalues;Sforsafeenvironments;Pfor
parentandcaregiversupport;
I
forincomeandeconomic
sirengthening:Rforresponseandsupportservices;and
Eforeducationandlifeskills.Therearealsotwocross
CUtingactivities(multisectoralactionandcoordination,and
monitoringandevaluation)thatconnectsthe
seven
Stategiesandmonitortheextentoftheirimplementation
andimpactontheproblem.
preventionprogrammes
TheCOVID-19pandemicandviolenceagainst
children(133)
TheCOVID-19pandemicandsocietiesresponsetoit
affectsallaspectsofourlives.Schoolclosureshave
impactedsome1.5billonchildren.Movementrestrictions.
lossofincome,isolation,andovercrowdinghaveheightened
levelsofstressandanxietyinparents,caregiversan
children,andcutfamiliesandindividualsofffromthei
usualsourcesofsupport.
Theseconsequenceshavealteredtheprevalencean
patternsofinterpersonalviolence.Decreasesinhomicide
andviolence-relatedinjuriesreceivingemergencymedici
treatment(whichmostlyinvolveolderadolescentsandadu
males)havebeenreported,particularlywherelockdow
wereaccompaniedbybansonalcoholsales.Spikesinca
tohelplinesaboutchildabuseandintimatepartnerviolen
havebeenobserved,alongsidedeclinesinthenumber
childabusecasesreferredtochildprotectionservices.
increaseinpotentialoractualonlineharms,including
sex
exploitationandcyber-bulyingresultingfromincrea
internetusebychildren,hasalsobeenidentified.
economicdevastationwroughtbyCOVID-19
and
responsetoitmaytakeyearstoovercome,andco
exacerbateeconomicinequalities,poverty,unemploym-
andhouseholdfinancialinsecurity.
he
startegiesandapproachesofINSPIREforpreventing
dTespondingtoviolenceagainstchildrenareasfollows
Strategy
Approach
mplementation
and
enforcement
l
laws
Lawsbanningviolentpunishmentof
childrenbyparents,teachersorother
caregivers
Laws
criminalizingsexualabuseand
exploitationofchildren
Lawsthatpreventalcoholmisuse
eLawslimitingyouthaccessto
lirearmsandotherweapons
Norms
and
values Changingadherencetorestrictive
andharmfulgenderandsocialnorms

161. SOCIALWELFAREFRtiGHAMME 681
Supplementarynutrition(therapeutic
.ofmanhildrensutferingfrom2ndand3rddegree
NutritionProgramneforAdolestent
Girlswasapproved
ne
year2009-10,onapilotprojectbasis.Theproject
1s
ngimplementedin51identilieddistrictsfromthemajor
es.
Undernourishedadolescentgirlsintheagegroupo
to 19years(withbodyweightlessthan30kgintheage
groupol11to15yeatsand35kgintheagegroupol
ars)
arecoveredunderthescheme.6kgofIree100d
grainisprovidedtocachbeneliciarypermonth.ne
programmeisbeingimplementedthroughtheadministrätive
Set-upolICDSschemeatthestate,district,blockand
AnganwadiCentrelevel.
iutrition
nChildrensutferingirom4thegreemalnutrition
ndedhospitalization.
ritjion
andhealtheducation
\utritionpducationandhealtheducationisgiventoall
15-45years.givingpriorityto
theagegroup
Npectantmothers.Itisimpartedbyspecialiy
singcoursesinVillageduringhomevisitsby
ganwadi
workers.
Inmunization
izationofchildrenagainst9vaccinepreventable
PoshanAbhiyan(138)
overnmentofIndiahaslaunched"PoshanAbhiyan"on
oth
December2017foraperiodofthreeyearscommencing
irom2017-18,inall36states/UTs.Thegoalsaretoachieve
improvementinnutritionalstatusofchildrenfrom0-6years
adolescentgirls,pregnantwomenandlactatingmothersWith
fixedtargets.Itensuresconvergenceofvarious
programmes
i.e
anganwadi
services.
PradhanMantriMatruVandana
Yojana;schemesforadolescentgirlsofMinistryofWomen
andChildDdevelopment;JananiSurakshaYojana;National
HealthMissionofMinistryofHealthandFamilyWelfare
SwachhBharatMissionofMinistryofJalShaktietc.
325isbeingdone,whileforexpectantmothers.
izationagainsttetanusisrecommended.
Healthcheck-up
inchudes(a)antenatalcareofexpectantmothers;This
nOsthatalcareofnursirngmotherandcareofnewborn
anis(c)careofchildrenunder6yearsofage.Besides
munization.expectantmothersaregivenironandfolic
tabletsalongwithproteinsupplements.Aminimumof
abusicalexaminationsaredone.Highriskmothersare
aredtoappropriateinstitutionsforspecialcare.
Thehealthcareofchildrenunder6yearsofageconsists
Theobjectivesandtargetsareasfollows(138):
1.Preventandreducestuntingin
children(0-6years)
2.Preventandreduceundernutrition
By6percent
(2percent/year)
By6percent
(2percent/year)
1.Recordofweightandheightofchildrenat
periodicalintervals;
Watchovermilestones;
3Immunization;
4.Generalcheck-upevery3-6monthstodetect
disease,malnutritionetc.;
5.
andunderweightprevalencein
children(0-6years)
3.Reducetheprevalenceofanaemia
amongchildren(6-59months)
4.Reducetheprevalenceofanaemia
amonggirlsandwomeninthe
agegroup(15-49years)
Reducelowbirthweight
(LBW)
TheAbhiyanaimstoreducemalnutritioninthecountry
throughalifecycleapproach.
2.
By9percent
(3percent/year)
By9percent
(3percent/year)Treatmentfordiseaselikediarrhoea,dysentery,
respiratorytractinfectionsetc.whicharewidely
prevalent
Deworming:
1.ProphylaxisagainstvitaminAdeficiencyand
By6percent
(2percent/year)
5.
anaemia,and
8.Referralofseriouscasestohospitalhasalsobeen
providedfor. Two
moreschemesarebeingimplementedattheICDS
level.Theyare(a)RajivGandhiSchemeforEmpowerment
ofAdolescentGirls"SABLA"fortheagegroup11to
18yearstoimprovetheirnutritionalandhealthstatus;and
(b)IndiraGandhiMatritvaSahyogYojana(IGMSY),under
whichconditionalcashtransferwillbemadetopregnant
andlactatingmothersinordertoinmprovetheirnutritional
andhealthstatus(65).
Healthrecords:Healthrecordsofthechildren,antenatal
aTe
anddeliverycardetc.aremaintained.Acard
0ntainingthehealthrecordofthechildisgiventothe
mother.
>.
Non-formal
pre-schooleducation
Cldrenbetween
theages3-6yearsareimpartednon
H
pre-schooleducationinananganwadiineach
gewithabout1000population.Theobjectiveisto
dOpportunitiestodevelopdesirableattitude,values
Attheendof2019,about7,075ICDSprojectsand
13.77lakhAnganwadiCentres/Mini-Anganwadi
Centres
werefunctionalinthecountry.About305.09lakhchildren
arepre-schooleducationbeneficiariesand836.25lakh
supplementarynutritionbeneticiariesarechildrenand
pregnantandlactatingmothers.
Theadministrativeunitofan1CDS
projectisthe
"communitydevelopmentblock"inruralareas,the"tribal
developmentblock"intribalareasandagroupofslumsin
urbanareas.Inselectionotprojectareaspreferencewas
giventoareaspredominantlyinhabitedbybackwardtribes,
backwardareas,draughtproneareasandareasinwhich
nutritionaldeficienciesarerampant.Therural/urbanproject
hasapopulationof100,000andatribalprojectabout
35,000population.Thenumberofvillagesintherural
projectmaybe100whileintribalareas,itmaybeonly
about50,takingintoaccountthedifticultterraininwhich
and
behaviour
patternamongchildren.Locallyproduced
n etoysandmaterialareusedinorganizingplay
nd
creative
activity.
emes
foradolescentgirls(65)
present,
thereare"Kishori twoschemesforadolescentgirlsviz.
AdoleseaktiYojana"and"NutritionProgrammefor
aolescent
Girls"
shori
Shakti
YojanantrastructurTe
n
the
isbeingimplementedusingthe
of1CDS.
Thehemetargetsadolescentgirls
selfdo.oupof11to18yearsandaddressestheirneeds
umericpment,nutritionandhealthstatus,literacyand
calskills,
vocationalskillsetC.

162. 682
REVENTIVE
MEDICINE
INOBSTETRCSPAEDAII
A
thetribalprojectsarelocated.Thefocalpointforthe
deliveryofintegratedearlychildhoodservicesunderthe
ICDSschemeisthetrainedlocalwomanknown
as
Anganwadiworker
(AWW).Other
functionariesinthe1CDS
aretheChildDevelopmentProjectOfficer(CDPO),who
is
inchargeof4Supervisors(MukhyaSevika)and100AWWs.
EachSupervisorisresponsiblefor20-25
anganwadisand
actsasmentortoAWWs;assistsinrecordkeeping,visitsof
healthpersonnelandorganizingcommunityvisits;and
provideson-the-jobtrainingtoAWWs.Anganwadiworker
isthe
multipurposeagent,selectedfromthecommunity.
AWWprovidesdirectlinktochildrenandmother;assists
CDPOinsurveyofcommunityand
beneficiaries;organizes
non-tormaleducationsessions;provideshealthand
nutritioneducationtomothers;:assistsPHCstaffin
providinghealth
immunization,feedingandpre-schoolattendance;liaises
withblockadministrator,localschool,healthstaff
annd
community,andworksforothercommunitybasedactivities,
e.g.,familyplanning.
Highrateofmortalityand
morbidityhas
associatedwith
pregnancyand
childbirthin
pubertal
by
be
an
adolescent
girls.Thisproblemisnowcompoun
aeP
dramaticriseinthenumberofpregnancies,both
andunwanted,
amongadolescents,whoareato
tiltcatrcn
ot
bealth
am
tran
diseases
moreoften.Ihere
appearsalsotobe
an
sittomoreabortionsand
contractingsexually
also
havi
thenumberofabandonedandabusedchildron
lovied
sei
adolescent
topersist,much
mothers.
of
As
the
long
energy,
asthese
creativity
problems
and
av
ideal
nt
of
youthwillbelosttosociety.wever,theproblerrns
are
prracneS
nc
ntarmin7
cial
de
are
preventable,andeffortstoeliminatethemmustinvol
ociety
needs
youngpeoplethemselves,Contribufinginwaysapnyehe
totheirparticularcultures.
Societytodaydemands
moreofyoungpeopletha.
before.Withthedeclineof
theextendedfamily
er
autonomy
isexpectedof
them,especiallyinthe
eater
children;increasingurbanizationandindustrial
of
meansthateconomicindependence
isachieved0n
throughmoreeducationandtraining.EarlyparonsOnly
PrOgran
health
Advoca
servicesS
maintains
recordso
Using
knowle
factor
sexua
beha
TheGovernmentofIndiaiscommittedtochild
developmentasapolicypriorityandissteadilyexpanding
ICDSprogrammewiththeultimateaimofreachingevery
child.Theimpactoftheprogrammeonthelives
ofchildrenisevidentinseveralcrucialindicators
particularlyforgirls,maylimitorpreclude
social
nthood,
educationaldevelopment
andtheabilitytoachiero
statusinsocietyandis
assoCiatedwithgreatermorbidit
mortality.TheWorldFertilitySurveyobserved
ani
and
s
increasedbirthweight,reducedincidenceofmalnutrition,
increasedimmunization
relationshipbetweenfertilityandtheeducationof
wornen:
se
Mob
20
Eapp
womenwithnoeducafion
have,onaverage,twiceas
man
childrenasthosewithsevenormoreyearsofschoolin
Corollariesofthisfindingarethencreasedearningpower
of
educatedwomen,theirimprovedstatuswithinthefami
andthegreatercontroltheyareabletoexerciseovert
thei
coverage,
infantandchildmortalityrateinareascoveredbythe
andareduced
ICDS(118).
Fac
Healthofadolescents
Theterm"adolescence"hasbeendefinedasincluding
thoseagedbetween10and19,and"youthasthose
between15and24;"youngpeople"isatermthatcovers
bothagegroups,i.e.thosebetweentheagesof10and24.
Trueadolescence,however,beingtheperiodofphysical,
psychologicalandsocialmaturingfromchildhoodto
adulthood,mayfallwithineither
developmentthattakesplaceinadolescenceisgenerally
uneven,inthatphysicalmaturitymaywellbeachievedin
advanceofpsychologicalorsocialmaturity;inmost
societies,infact,reproductivecapabilityisnowestablished
atanearlieragethaninthepast.
ownlives.
PRE
Amoreuniversalconsequenceofearlyandmore
frequentchildbearingistheincrease
inpopulationsizeand
growthrate.Wheregirlsmarryat16,the
agegapbetween
successivegenerationsmaybelessthan20years;this
gan
maywidentoasmuchas30yearswheretheageat
marriageis25.Thesexualbehaviourandreproductive
patternsofyoungpeoplearehighlysusceptibletosocial
influencesandrelatedtotheirownsenseofpsychological
well-being.
Age
Slerin
piotecs
act
th
shoulc
agerange.The
phenc
chan
The
Theimportanceofthehealthofadolescentshasstarted
toreceiveincreasingrecognition,particularlyindeveloping
countrieswherefouroutoffiveoftheworld'syoungpeople
dive,andwheremorethanhalfthepopulationisunderthe
ageof25.Theseyoungmenandwomenare,orwill
ecome,theparentsofthenextgeneration.Theymustbe
giveneveryopportunitytodeveloptotheirfullpotentialas
ealthyindividuals.
Althoughanadolescentgirlislikelytogivebirthandrear
herchildrenwithinthecontextofanextendedfamily,the
riskssheandherchildrenrunotillness,injuryanddeathare
fargreaterthanthoseforamaturewomaninhertwenties.
Thechancesofanaemia,developingduringpregnancy,and
ofretardedfetalgrowth;prematurebirthandcomplications
duringlabourareallsignificantlyhigherfortheadolescent
mother,asaretherisksofherowndeathduringpregnancy
orchild-birth.
gEtlc
Formaleducationofgirlsgenerallyendswithmarriage,
andfromthenontheirsocialstatusmaywelldependon
fecundity.Anadolescentgirlwhoprovestobeinfertile(or
whosehusbandisinfertile)runstheriskofbeingrejectedby
bothhusbandandfamilyandthusoflosingwhatlittlestatus
shehas.Thesecondmajorsetofproblemsofreproductive
healthinadolescenceresultsfromtheprofoundsocio-
economicchangestakingplaceinmostdeveloping
countries.Theaverageageofmenarchehasfallen,thereisa
trendtowardslatermarriage,andyoungpeopleareoften
lessdirectlysupervisedthanwasthecaseinthepastallof
whichhavetheeffectofincreasingtheopportunities
tor
sexualencounter.Sincethesubjectofadolescentsexuality
remainstabooinmostsocieties,thereiswidespread
ignoranceamongyoungpeopleoftherisksassociatedwith
unprotectedsexualactivity.Sourcesofinformationand
Becauseadolescentsarelessvulnerabletodiseasethan
aeveryyoungandtheveryold,healthproblemsspecificto
eiragegrouphavebeengivenlittleprominenceuntilnow.
oreover,insocietieswheregirlsinparticularhave
aditionallymarriedatanearlyage,adolescencehasbeen
gardedmerelyasabriefinterludebetweenpubertyand
arriage.Astheaverageageofmenarchehasfallen,and
hanincreasingtrendtowardslatemarriage,however,this
iodhasbeenextendedandtraditionalattitudehasbegun
hange.Atthesametime,theinfluenceofthefamilyhas
lined,urbanizationandmigrationhavebecomemore
mon,andyoungpeoplehavebeenincreasinglyexposed
hemassmediaallfactorsthatcontributetomajor
gesinsocialandsexualbehaviour.

163. pflve
advicearerarelyilableoraccessibleto
aceptivesaressometimesexacerbbyalcoholand
683
PRIVENIIVEMEDICNEANO
CiERIATRCS
Odpeopleiscontinuallyontheincrease.
Thesetrendsare
appearinginallcountrieswheremedicalandsocialservices
arewelldevelopedandthestandardoflivingishigh
Intheyear2019,therewerean
estimated694millionold
ersonsin
theworld,ofwhich540
millionwerelivingin
developingcountries(5),ItalyandJapanhavethehighest
proporionofolderpersons(about24percentand16per
centrespectivelyintheyear2019).By2025,thenumberot
clderlypeopleisexpectedtorisemorethan1.2billionwith
about840millionoftheseinlow-incomecountries.InIndia,
althoughthepercentageofagedpersonstothetotal
populationislowincomparisontothedevelopedcountries,
nevertheless,theabsolutesizeofagedpopulation
15
Considerable.Fortheyear2019theestimatesare:9.3per
centoftotalpopulationwereabovetheageof65years.
ThisprofoundshiftintheshareofolderIndians,bringswith
itavarietyofsocial,economicandhealthcarepolicy
challenges(141).
additionimpulsivesexubehaviourandnon-use
use.
sher
ofmajorapproachestoreducingproblemsby
ationofthecontributingfactorswillservetopromote
oalthamongtheyoungandthustoimprovehealth
ialdevelopmentoftheircommunities.These
chesincludethe
following
nforming,educatingandsensitizingkeygroupsin
Ociety
toindividualhealthandsocialdevelopment
needs.
Advocatingappropriatepolicy,legislationand
programmesforpromotingadolescentreproductive
health.
Usingappropriateandinnovativeresearchtoimprove
knowledgeot,anddisseminateintormationabout,the
factorsthatintluenceanddetermineyoungpeople's
sexual,contraceptiveandreproductivedecisionsand
behaviour
Modifying,extendingandevaluatingservicesspecially
designedtomeetyoungpeople'sneeds.
Mobilizingtheenergy,creativityandidealismofyoung
peopleinpromotingheal
appropriateactivitiesintheircommunities.
Facilitatingactiontoextendeducationopportunities
forgirls.
Healthproblemsoftheaged
(1)PROBLEMSDUETOTHEAGEINGPROCESS
Nooneknowswhenoldagebegins.The"biologicalage"
ofapersonisnotidenticalwithhis"chronologicalage".Itis
saidthatnobodygrowsoldmerelybylivingacertainnumber
ofyears.Yearswrinkletheskin,butworry,doubt,tear,
anxietyandself-distrustwrinklethesoul.Whileageingmerely
standsforgrowingold,senescenceisanexpressionusedfor
thedeteriorationinthevitalityortheloweringofthe
biologicalefficiencythataccompaniesageing.Withthe
passageoftime,certainchangestakeplaceinanorganism.
Thesechangesare,forthemostpartdeleteriousand
eventuallyleadtothedeathoftheorganism.Ourknowledge
abouttheageingprocessisincomplete.Wedonotknow
muchaboutthedisabilitiesincidenttotheageingprocess.
Howeverthefollowingaresomeofthedisabilitiesconsidered
asincidenttoit;(a)senilecataract,(b)glaucoma,(c)nerve
deafness,(d)osteoporosisaffectingmobility,(e)emphysema,
()failureofspecialsenses,(g)changesinmentaloutlook.
Thislistisnotexhaustive;weneedtoknowalotmoreabout
thedisabilitiesincidenttotheageingprocess.
anddeveloping
PREVENTIVEMEDICINEANDGERIATRICs
Ageingisanaturalprocess.Inth
isanincurabledisease",butmorerecently,SirJames
erlingRosscommented"Youdonothealoldage.You
btectit;youpromoteit;youextendit"(140).Thesearein
ct
thebasicprinciplesofpreventivemedicine.Oldage
Ouldberegardedasanormal,inevitablebiological
enomenon.Thestudyofthephysicalandpsychological
nanges
whichareincident
necareoftheagediscalledclinicalgerontologyor
eriatrics.Anotheraspectofgerontologyissocial
erontologywhichwasbornontheonehandoutofthe
stinctsofhumanitarianandsocialattitudesandonthe
heroutoftheproblemssetbytheincreasingnumberof
0people.Experimentalgerontologyisconcernedwith
esearchintothebasicbiologicalproblemsofageing,intoits
stology,biochemistry,pathologyandpsychology.The
s
ofstudiesrangefromstudiesofpopulationsthrough
Viduals,organs,systems,tissuesandcells,downtothe
ecularlevel.GERIATRICGYNAECOLOGY: Withthe
ening
span
oflifeanewchapteringynaecology
iC
gynaecology-isfastopeningup.Morepatientsare
Sngforrepairofprolapseofvaryingdegrees,non-
S vaginitis,ovariantumours,psychicaberrationsand
hoproblems.Thereisamplescopeforresearchinto
treatment
inhospitaland
preventive
geriatrics
lecting
theaged.
wordsofSeneca;"Old
oldageiscalledgerontology.
(2)PROBLEMSASSOCIATEDWITHLONG-TERM
ILLNESS
Certainchronicdiseasesaremorefrequentamongthe
olderpeoplethanintheyoungerpeople.Theseare
(a)DEGENERATIVE DISEASESOFHEARTANDBLOOD
VESSELS:Ofparticularimportanceaftertheageof40,are
thedegenerativediseasesoftheheartandbloodvessels.
Theinnerwallsofarteriesbreakdown,andalipoidmaterial
isdeposited.Thisintimeisreplacedbycalciumwhichleads
tonarrowingofbloodvesselsoratherosclerosis.Thisleads
todiminishedbloodsupply,thrombusformation,ruptureof
bloodvesselsandhighbloodpressure.Nosinglefactorhas
beenidentifiedasthecauseofatherosclerosis.Diet,
heredity,overweight,nervousandemotionalstrainhaveall
beenimplicated.Cardiovasculardiseasesarethemajor
causesofdeathinthedevelopedcountries.Areductionof
bodyweightandmodificationofthehabitsoflifeare
neededtodecreasethestrainonheartandbloodvessels.By
these,itispossibletoleadalongerandmoreusefullife.
(b)CANCER:Thedangerofcancerloomslargepastmiddle
ife.Inthedevelopedcountries,cancerisaleadingcauseof
death.Theincidenceofcancerrisesrapidlyaftertheageof
40.Canceroftheprostateiscommonaftertheageof65.(c)ACCIDENTS
degenerative
andtherdiseasesofoldage;their
generalpractice;andfinallyinto
andtheepidemiologyofconditions
Size
oftheproblem
Discoveries
conditio inmedicalscienceand
improvedsocial
iesisover80years.Theagestructureofthepopulation
Spanofauringpastfewdecadeshaveincreasedthelife
Countripe
he
expectationoflifeatbirthindeveloped
n
the
d
eopedcountrieshas
so
evolvedthatthenumbersof Accidentsareahealthprobleminthe

164. 704
NUTRITONANDHEALTH
ismosteffectiveinreducingbloodglucrs
levelsascomparedtoother
gums
Fibrehavenometaboliceffects.Hou
fibrecandecreasethe
absorptionofvaluable
RtarErns
area
s
ntial
nitrients
ClassificationGlrange
ucose
and
cholet
Examples
LowGI 55orlessmostfruitandvegetables(except
owever
Potatoes,
watermelonandsweet
Corn),wholegrains,pastafoods,
beans,lentils
retends
t
Thereisconflictingevidenceastowhethericron
andzinc,andreduce
theirbio-availabilituesim
well-balanceddietobtainenoughtoughageple
wh
qualitativeandquantitativedecreaseinfibnsiderin
itentazs
Ca
no
iher
tittrients
sthestE
them
foc
somevitaminsandmineralslikecalcium,
mall
amOunts
Medium
G1 56-69
sucrose,basmatirice,brownrice
HighGI 70or cornflakes,bakedpotato,
somewhite
ricevarieties(e.g.jasmine),white
bread,candybarandsyruPyfoods.
stances
tme
vit
Vitamirns
arg
more
content
o
dietar
overthepastmanydecades,anincreasein
G-Glycaemicindex
particularlyfromcereals
emergeasarecommend.yft
inexcessof60
goftibre
overadaycanredeon,
Ina
absorptionandcausebowelirritation(9).AdailDutrio
about30gramsofdietarytibreper2000kcaliintate
estimatesofdietaryfibreintakeindifferentincablep
DIETARYFIBRE
Bydefinition"Dietaryfibreistheremnantsoftheedible
partofplantsandanalogouscarbohydratesthatareresistant
todigestionandabsorptioninthehumansmallintestine
withcompleteorpartialfermentationinthehumanlarge
intestine
Itincludes
polysaccharides,
oligosaccharides,
ligninandassociatedplantsubstances.Dietaryfibreexhibits
oneormoreofeitherlaxation(faecalbulkingandsoftening;
increasedfrequency;andorregularity),bloodcholesterol
attenuation,andorbloodglucoseattenuation.Organic
acids(butyricacid)andpolyols(sorbitol)arealsoconsidered
aspartoffibre.Animalfoodsdonotcontainanyfibre.
ritanun
Dasa
me
segmerts
reportedfromwesternIndiaarerural-39
gram
arttcula
menand30g/dayforwomen;tribal19g/dau
fayfor
15g/dayforwomen;industrial
-41gdaufen
an
TanEnance
beet
Ceter
sOmewnas
seases.
For
men
31g/dayforwomen;highincomegroup31gldat
and
and21g/dayforwomen;middleincomegroup-43men
menand22g/dayforwomen;andlowincormay
for
actual
ne
24g/dayformenandZ0g/dayforwomen(11)Tu
nature
ofcerealsquantityoffibreintakedependsuponthenatur
pulses,wholegrain,vegetablesandmilletsusedTheals
fibrecontentofcommonfoodsareasshowninTablo
Vitama
Typeandsources
COnverte
nternatic
and
pre
eSpec
and
a
pa
TABLE4
Dietaryfibreshavebeencharacterizedbyitssource,e.g.
cereal,vegetableandfruitsoritssolubilityinwater
-soluble
(partlyorfully)orinsoluble.Bothcharactersofsolubilityare
essentialforhealthpromotion.
Digestibilityoffibre
is
determinedbyphysiochemicalandstructuralpropertiesofthe
dietarycomponentandtheprocessused.Whenexposedto
longerdurationofdegradativeconditionsinlargeintestine,
morefibreisdigested.Itformsthesubstanceforfermentation
byintestinalmicrobes.Itisthroughthismechanismthatpart
ofenergyfromresistantstarchisrenderedavailable.Apart
fromtheenergyyieldingreactionsduringdigestion,at
differentpH,theactionofenzymesondietaryfibrespromotes
interactionbetweennutrients.
Italsochangesthepatternof
microbescolonizingthecolonandthusthemetabolic
productsofsuch
fermentationoverthetime.Vegetariansmay
havedifferentdigestionpatternthanthatofthenon-
vegetariansandthusderivedifferenthealthbenefits.This
knowledgeofprobiotics
characterizedbyhelpfulmicrobes
andprebiotics
(substratespromotingthe
colonizationof
probioticstrains)hasopenedupnewareasforresearch(9).
DifferentdietaryfibrefractionsinselectedIndianfoed
FoodGroupFoodName DietaryFibre(g100g
TotalInsolubleSoluble
for
CerealsandBajra
11.49
10.22
11.18
2.81
11.23
9.14
8.49
9.51
1.99
9.63
the
2.34
1.73
Jowar
Ragi
Rice,raw,milled
Wheat,whole
millets
itam
orU
1.61
082
1.60
Grain
Bengalgram,whole
Greengram,whole
Rajmah,red
Soyabean,
brownn
25.22
17.04
16.57
21.55
22.70
14.59
13.86
16.56
2.52
244
2.70
5.00
legumesS
4.41 3.21
Greenleafy
vegetables
Amaranthleaves,
1.20
green
Colocasialeaves,
5.60 4.32 129
green
Drumstickleaves
Tamarindleaves,
tender
8.21
10.70
6.12
9.34
2.10
1.36
Brinjal
Drumstick
Ladiesfinger
3.98
6.83
4.08
2.84
5.60
2.80
1.14
1.23
1.28
Other
Originalestimatesoffibrecoveredallthatwasinsoluble
inboilingwaterorindiluteacidandalkaliconditions.Itwas
reportedascrudefibre',whichmayincludeallstructural
fibre,
cellulose,ligninand
haemicellulose.Itisrelatedto
digestibilityandhasthepropertyofholdingwaterand
swellingpropertiesofthediet.Itaddstothebulkofthe
food,favourssatiety,increasestransittimeofthefoodinthe
gutandisanactive
substrateinthelargeintestineforrelease
ofimportant
functional
componentslikeorganicacidsand
nutraceuticals.
Mostlycomplex
carbohydrates,suchas
polysaccharidesi.e.
cellulose,
haemicellulose,pectinanda
varietyofgums,
mucilagesformthefibre.
vegetables
Apple,big
Pineapple
Sapota
2.59
3.46
.60
1.43
2.88
8.46
1.14
1.16
0.59
Fruits
Rootsand
tubers
Carrot,orange
Potato,brownskin
Tapioca
4.18
1.71
4.61
2.81
137
0.58
1.13
3.85
0.76
4.60
26.55
27.63
30.61
Condiments
Chillies,red
Fenugreekseeds
Pepper,black
Almond
31.15
47.55
33.16
13.06
17.1
14.10
andspices
10.55
13.57
10.63
2.54
2.52
3.59
3.41
Nutsand
oilseedsSGingellyseeds,black
Mustardseeds
Dietaryfibreisknowntobeassociatedwithreduced
incidenceof
coronaryheartdisease.The
mechanismofits
actionisattributedtoitsbindingtobilesaltsandpreventing
its
reabsorptionandthus
reducing
cholesterollevelin
circulation.Thefibre,
particularlythegumandpectin,when
ingestedwithadiet,arereportedtoreduce
post-prandial
glucose
levelinblood.Recentstudieshaveshownthatgum
presentin
fenugreekseeds,whichcontains40percentgum,
0.35
3.11
2.76
Buttonmushroom,
fresh
Mushrooms
3.02
2.03
0.99
Shiitakemushroom,
fresh
39.12
35.64
3.48
Oyster
mushroomn,
dried
Source:(11)

165. 206 NUTRITIONANDHEALTH
AssessmentofvitaminAdeficies
Theformulationofaneffective
inter
Ookingsmoothandshiny,itappearsmuddyandwrinkled.it
nasbeenwelldescribedas"emerginglikesandbanksat
recedingtide"whenthechildceasestocry(Zl). orpreventionofvitamin
Adeficiencuention
ogTamimg
populat
characterizationoftheproblem.Thisis
degine
(c)Bitot'sspots
surveysemployingbothclinicaland
bioch
by
iteta
These
surveys(prevalencesurveys)aredonical0-5itotsspotsaretriangular,pearly-whiteoryellowish,
amyspotsonthebulbarconjunctivaoneithersideofthe
cornca.Theyarefrequentlybilateral.Bitot'sspotsinyoung
childrenusuallyindicatevitaminAdeficiency.Inolder
ndividuals,thesespotsareofteninactivesequelaeofearner
disease.
children(6monthsto
6years)whoareon
specia
Pre
t
ThecriteriarecommendedbyWHO(18
are
Table6.Thepresenceofanyoneof
thesgiv
beconsideredasevidenceofaxerophthaleria
sh
shoulhalmia
problem
i
thecommunity.
TABLE
66(d)Cornealxerosis
Prevalencecriteriatordetermining
the
xerophthalmiaproblem
Ihisstageisparticularlyserious.Thecorneaappears
aul,
dryandnon-wettableandeventuallyopaque.It
does
nothaveamoistappearance.Inmoreseveredeticiency
theremaybecornealulceration.Theulcermayhealleaving
acornealscarwhichcanaffectvision.
Prevalence
inpopulation
atrisk(6months
to
6year
Criteria
more
thanIpercent
Nightblindness
Bitot'sspots
Cornealxerosis/corneal
(e)Keratomalacia
morethan0.5per
cent
morethan0.01per
cent
Keratomalaciaorliquefactionofthecorneaisagrave
medicalemergency.Thecornea(apartorthewhole)may
becomesoftandmayburstopen.Theprocessisarapid
one.Ittheeyecollapses,visionislost.
ulceration/keratomalacia
Cornealscar morethan0.05per
cent
Serumretinol(less
than10mcg/dl)
more
than5per
cent
EXTRA-OCULAR MANIFESTATIONS
Source:(18)
Thesecomprisefollicularhyperkeratosis,anorexiaand
growthretardationwhichhavelongbeenrecognized.Ihey
arenon-specificanddifficulttoquantify.Recentstudies
seemtoindicatethatevenmildvitaminAdeficiencycauses
an
increaseinmorbidityandmortalityduetorespiratory
andintestinalinfection(22).DeficiencyofvitaminAhas
recentlybeenlinkedtochildmortality(23).
Recommendedallowances
Thepresentcommitteerevisedthecarotene
conversion
ratiotoaccount
fortisSueconversion,andgeneral
conversionfactorof6:1isrecommendedtorall
carotenoids
exceptB-cryptoxanthineanda-carotenewhereaCFof121
isrecommended.lhedetailedrecommendationsareasgiven
inTable28.Treatment
VitaminAdeficiencyshouldbetreatedurgently.Nearly
alloftheearlystagesofxerophthalmiacanbereversedby
administrationofamassivedose(200,000
ITUor110mgof
retinolpalmitate)orallyontwosuccessivedays(24).All
childrenwithcornealulcersshouldreceivevitaminA
whetherornotadeficiencyissuspected.
Toxicity
Anexcessintakeofretinolcausesnausea,vomiting,
anorexiaandsleepdisordersfollowedbyskin
desquamation
andthenanenlargedliverandpapillaroedema.High
intakesofcarotenemaycolourplasmaandskin,butdonot
appeartobedangerous(19,27).Theteratogenic
effectsof
massivedosesofvitaminAisthemostrecenttocuso
interest(28).
Prevention
Preventionand/orcontroltakestwoforms
(a)improvementofpeople'sdietsoastoensurearegular
andadequateintakeoffoodsrichinvitaminA,and(b)
reducingthefrequencyandseverityofcontributoryfactors,
e.g.PEM,respiratorytractintections,diarrhoeaand
measles.Botharelongtermmeasuresinvolvingintensive
nutritioneducationofthepublicandcommunity
participation.
VITAMIND
ThenutritionallyimportantformsofVitamin
Dinmat
areCalciferol(VitaminD,)andCholecalciferol(Vitamin
Calciferolmaybederivedbyirradiationoftheplant
ste
ergosterol.CholecalciferolisthenaturalyOCEh
preformed)vitaminDwhichisfoundinanimalfatsanha
liveroils.Itisalsoderivedfromexposureto
UVraysmin
SunlightwhichconvertthecholesterolintheskintoVtau
D.VitaminDisstoredlargelyinthefatdepots.
SincevitaminAcanbestoredinthebodyfor6to9
monthsandliberatedslowly,ashortterm,simpletechnology
hadbeenevolvedbytheNationalInstituteofNutritionat
Hyderabad(India)forcommunitybasedintervention
againstnutritionalblindness,whichhassubsequentlybeen
adoptedbyothercountries(25)Thestrategyisto
administerasinglemassivedoseof200,00010ofvitaminA
inoil(retinolpalmitate)orallyevery6monthstopreschool
children(1yearto6years),andhalfthatdose(100,000IU)
tochildrenbetween6monthsandoneyearofage(24).In
thisway,thechildwouldbe,asitwere"immunized"
againstxerophthalmia.
six-monthlydosingseemsveryadequateasmeasuredby
VitaminD:Kidneyhormone
Majoradvanceshavebeenmadeinrecent
sin
our
understandingofthemetabolismotVitamitseli,
29t
isnowknownthatvitaminD,
De
metabolicallyinactiveunlessitundergoesod.,2
transformationintoseveralactivemetabol
HCC;1:25DHCC)firstintheliverandlaterin.protin
Thesemetabolitesareboundtospecincuaintestine
andarecarriedtothetargettissues-boneaarded
as
hasbeenproposedthatvitaminDshouldbeEg
enous
In
the
kidne
Theprotectionaffordedby
clinicalsignsofdeficiency(26).

166. 707
nne
(30)becauseitdoesnotmeettheclasslc
vitamin,thatis,asubstancewhlclhmustbe
oth
ricketsandosteomalaciawerefrequentlyreporte
ndl,althoughtheydonotappeartobeaproblem
o
pubichcalhimportance,Intheworldasawhole,thieir
prevalencehasdeclinedasa1esultofchangesins0c
Customs(e.g.,purdahsystern),andtheexpansionofmother
andchildhealihserviceslendingtobettercareandfeeding
ofinlantsandchildren(3).InthedevelopingCounrle
oday,ricketsasamenacetochildhealthisoyershadoved
bytheprevalenceofprotein-energy-malnutrition.
heliiluonofa
vito
Mainhdytosynthesizeit,lnfact,vitaminD,isnot
Ainey
hormone
(30)
bydietary
meanscauseolalackofcapacityin
allinconditionsoladequatlesunlight.
y
requircnentat
keary
ethesizedinthebodyinaclequateamountsby
the
haman
bocl
ansuretosunlighteventorminutesperday.
sinple
cxpoSUretosunl
Functions
Prevention
The
unctionsofvitaminDareassummarizedinTable7.
TABLE7
Preventionmeasuresinclude(a)educatingparentsto
exposetheirchildrenregularlytosunshine;(b)periodi
dosing(prophylaxis)ofyoungchildrenwithvitaminD;and
(c)vitaminDfortificationoffoods,especiallymilk.Sorne
industrializedcountriesstillcarryoutthelastmeasure
Periodicdosingandeducationappeartobethenost
praciicalapproachesindevelopingcountries.
FunctionsofvitaminDanditsmetabolites
Promotesintestinalabsorplionofcalclumand
phosphorus
Stimulatesnormalmineralization,enhances
bonereabsorption,aftectscollagenmaturation.|
Increasestubularreabsorptionofphosphate,
Variableeffectonreabsorptionofcalcium
Permitsnormalgrowth.
ntestine
Bona
idney
Fraser(32)urgescautionconcerningoral
supplementation,becauseorallyadministeredvitaminD
appearstobypasstheprotectivemechanismthatprevent
excessive25(OH)D,formation.Themarginofsafetywith
oralvitaminDbetweenthenutrientrequirementandtoxic
intakeisnarrow.
Dther
Source:57
Sources
VilaminDisuniquebecauseitisderivedbothfrom
sunlight
andfoods.(a)Sunlight:VitaminDissynthesized
by
thebodybytheaction
otfUvraysofsunlighton
-dehydrocholesterol,whichisstoredinlargeabundancein
theskin.ExposuretoUVraysiscritical;thesecanbefiltered
off
by
airpollution.Dark-skinnedracessuchasNegros,also
sufferfromthisdisadvantagebecauseblackskincanfilteroff
upto95percentofUVrays.(b)Foods:VitaminDoccurs
onlyinfoodsofanimalorigin.Liver,eggyolk,butterand
cheese,andsomespeciesoffishcontainusefulamounts.
Fishliveroils,althoughnotconsideredtobeafood,arethe
richestsourceofvitaminD.Humanmilkhasbeenshownto
VitaminDisstoredinthebodyinfattytissuesandinthe
liver.Anexcessiveintakeisharmfulandmayresultin
anorexia,nausea,vomiting,thirst,anddrowsiness..The
patientmaylapseintocoma,whilecardiacarrhythmiasand
renalfailuremayoccur.Theeffectsaredueto
hypercalcaemiainducedbyincreasedintestinalabsorption
andmobilizationofcalciumfrombone.Recentliterature
containswarningagainsttheadministrationofamountsof
vitaminDthatgreatlyexceedacceptedrequirementlevels.
Thiswarningappliestopregnantwomenalsosince
manifestationsofhypercalcaemiamaydevelopinutero(4).
containconsiderableamountsofwater-solublevitamin
Dsulphate(31).OthersourcesofvitaminDarefoods
artificiallyfortifiedwithvitaminD,suchasmilk,margarine,
vanaspatiandinfantfoods.DietarysourcesofvitaminDare
asgiveninTable8.
Dailyrequirements
TheexpertcommitteeofICMRemphasizesimportanceof
outdoorphysicalactivitiesasameansofachievingadequate
vitaminDstatusinatropicalcountrylikeIndia.However,
underminimalexposuretosunlight,particularlyincertain
urbangroups,like1-2
yearoldchildren,aspecific
recommendationofadailysupplementof600IUis
suggested(11).
TABLE8
DietarysourcesofvitaminD
Hg/per100g Hg/per
100Og
VITAMINEButter
Eggs
Milk,
whole
0.1
0.5-1.5 Sharkliveroil30-100
(Tocopherol)
1.25-1.5 Codliveroil 200-750
VitaminEisthegenericnameforagroupofcloselyrelated
andnaturallyoccurringfatsolublecompounds,the
tocopherols.Ofthesealpha-tocopherolisbiologicallythe
mostpotent.VitaminEiswidelydistributedinfoods.Byfar
therichestsourcesarevegetableoils,cotton-seed,sunflower
seed,eggyolkandbutter.Foodsrichinpolyunsaturatedfatty
acidsarealsorichinvitaminE.Theusualplasmalevelof
vitaminEinadultsisbetween0.8and1.4mgper100ml(31).
Whilethereisnodoubtthatmanrequirestocopherolinhis
diet,thereisnoclearindicationofdietarydeficiency.Therole
ofvitaminEatthemolecularlevelislittleunderstood.The
currentestimateofvitaminErequirementisabout0.8mg/gof
essentialfattyacids.Ihisroughlyworksoutto7.5-10mg
tocopherolperdaydependingontheedibleoilused(11).
RecentlythecytotoxiceffectofvitaminEonhuman
lumphocytesinvitroathighconcentrationshasbeen
reported.Thisbeingso,cautionshouldbeexercisedagainst
themega-doseconsumptionofvitaminEinclinical
practice.
Halibutliveroil500-10,000
sh
fat
5-30
Deliciency
ickets:
VitaminDdeficiencyleads
torickets,which
llyobservedinyoungchildrenbetweentheageofsix
C andtwoyears.Thereisreducedcalcificationot
al0Ones.Thediseaseischaracterizedbygrowth
lsionsduetohypocalcaemia.Thereisanelevated
ncentration
ofalkaline
bonedeformity,muscularhypotonia,tetanyand
phosphateintheserum.Thebony
Chest
Hancude
curvedlegs,deformedpelvis,pigeon
Ihe
mil5on's
sulcus,ricketyrosary,kyphoscoliosis,etc.
ilestones
ofdevelopmesuchaswalkingandteething
ayed.(2) nalaciaIn
adults,vitamin
Ddeelaue
aeliciency
may
WOmody resultinosteomalaciawhich
occursmainly
tequirements
Ot
nen,
especially
duringpregnancyandlactationwhen
inentsofvitaminDareincreased.
T

167. 708 NLPRIONAND1AJF
Thiaminelosses
VITAMINK
Thiamineisreadilylostfromrice
milling.Beingawater-sof
placeduringwashingandcooking
foradvisingpeopletoeschewhigh
polished
eduring
amin,
furthe
of
rice.
Thi
thest
n
at
at
ve
VitaminKoccursinatleasttwomajorformsvitaminK
andvitaminRVitaminK,isfoundmainlyinfreshgreen
vegetablesparticularlydarkgreenones,andinsomefruits
Cow's
nmilkisarichersource(60meg/L)ofvitamin
Kthan
humanmilk(15meg/L).VitaminK,issynthesizedbythe
intestinalbacteria,whichusuallyprovidesanadequate
Supplyinman.Long-termadministrationofantibioticdoses
formorethanaweekmaytemporarilysuppressthenormal
intestinalflora,(asourceofvitaminK,)andmaycausea
deficiencyofvitaminK.VitaminKisstoredintheliver
TheroleofvitaminKistostimulatetheproductionand
or
thereleaseofcertaincoagulationfactors.InvitaminK
deticiency.theprothrombincontentofbloodismarkedly
decreasedandthebloodclottingtimeisconsiderably
prolonged.
parboiledorunder-milledrice
(see
thiamineinfruitsandvegetablesi
prolongedstorage
(55)hiamineisalerally
andincerealscoOkedwithbakingsoretr
absenceofberiberiis
page
Ti6
determined
bythe
local
o
culturalpracticesconcerningtheprocessing
a
NCreals
riceandofherfoodstuffs.
ThevitaminKrequirementofmanismetbya
combinationofdietaryintakeandmicrobialsynthesiSintne
uthedailyrequirementformanappearstobeabout
0.03mg/kgfortheadult.Newborninfantstendto
be
deficientinvitaminKduetominimalstoresofprothrombin
atbirthandlackofanestablishedintestinalflora.Soonalter
birth,allinfantsorthoseatincreasedriskshouldreceivea
SingleintramusculardoseofavitaminKpreparation
(0.1-0.2mgofmenadionesodiumbisulphiteor0.5mgof
vitaminK,)bywayofprophylaxis(33).
Deficiency
Thetwoprincipaldeticiencydiseases
Wernick'sencephalopathy.Beriberimauaeberk
forms(a)thedryformcharacterízed
hurinth
peripheralneuritis);(6)thewetform rveiny
involvement(cardiacberiberi);and(clierized
h
seenininfantsbefween2and4monthsantile
he
babyisusuallybreast-fedbyathíamine.e
whocommonlyshowssignsofperiphers
Wernick'sencephalopathy(seenofteneropat
ischaracterizedbyophthalmoplegia,
polune
eribenage.
The
affe
mehe
rurCcE34
in
alcshsc
euritis.
at
Deticienc
The
mas
andmentaldeterioration.
whofast.
Itoccurs
occasíona deticiency
Afewshortdecadesago,frankcases
ofhori
befrequentlyseeninthecoastaldistricts
ofAndsedwherepeopleeathighlypolishedrice.Investigaade
ICMRshowedthatsuchcasesarenowrareltthe
of
the
stats
clinicalsig
mElnour7sh
BGROUPOFVITAMINS
THIAMINE(B,) gcssttts
becauseofimprovedsoci0-economic
conditio
Thiamine(vitaminB,)isawater-solublevitamin.Itis
essentialfortheutilizationofcarbohydrates.Thiamine
Pyrophosphate(TPP),thecoenzymeofcocarboxylaseplays
apartinactivatingtransketolase,anenzymeinvolvedinthe
directoxidativepathwayforglucose.Inthiaminedeficiency,
thereisaccumulationofpyruvicandlacticacidsinthe
tissuesandbodyfluids.
nIcountered
tions
ven
wnen
diversificationinthedietconsumednow(36
may
have
TErornoto
SUSCEptIO
aivaysoc
B-compleK
Prevention
Beribericanbeeliminatedbyeducating
peanles.well-balanced,
mixeddietscontainingthiamine-tich
à
muliple
(e.g.,parboiledandundermil
rice)andto
Requirer
stopalcohol.Directsupplementationofhigh-riskqrOIneSources
lactatingmothers)isanotherapproach.Beriberitonde
There
ends
tdisappearaseconomicconditionsimprove
and
equiremne
For
turthe2
Thiamineoccursinallnaturalfoods,althoughinsmall
amounts.Importantsourcesare:wholegraincereals,wheat,
gram,yeast,pulses,oilseedsandnuts,especiallygroundnut.
Meat,fish,eggs,vegetablesandfruitscontainsmaller
amounts.Milkisanimportantsourceofthiamineforinfants,
providedthethiaminestatusoftheirmothersissatisfactory.
ThemainsourceofthiamineinthedietofIndianpeopleis
cereals(riceandwheat)whichcontributefrom60-85per
centofthetotalsupply.Thethiaminecontentofselected
foodstuffisgiveninTable9.
dietsbecomemorevaried(10).Ihedisease,ashasbeen
shown
isnotcompletelyvanquishedbuttheknowledaeant
resourcesneededtobringaboutitsdisappearance
aavailable(3). Niacin
ofcarbo
Recommendedallowances norma
Thebodycontentofthiamineisplacedat30mg.andif
morethanthisisgivenitismerelylostintheurine(19
Patientsonregularhaemodialysisshouldroutinelybegiven
supplementsofthiamine.Thiamineshouldalsobegiven
prophylacticallytopeoplewithpersistentvomitingor
prolongedgastricaspirationandthosewhogoonlongfasts.
ForfurtherdetailsseeTable28.
Stems.
B-compt
Typtoph=
macin
is
metabolfTABLE9
Dietarysourcesofthiamine
N-methy-
Foodsof
vegetableorigin
Foodsofanimal Sourc
mg/100g
mg/100g
origin
RIBOFLAVIN(B,)
Food
Wheat(whole) 0.45Milk,cow's 0.05
meat
Riboflavin(VitaminB,)isamemberoftheB-group
Vitamins.Ithasafundamentalroleincellularoxidation.t
playsanimportantroleinmaintainingtheintegrity
or
mucocutaneousstructure.Itisaco-factorinanumbera
enzymesinvolvedwithenergymetabolism.t1S
involvedinantioxidantactivity,beingaco-tactortor
enzymeslikeglutathionereductaceandisrequiredtot
metabolismofothervitaminslikevitaminBo,niacit
vitaminK(9).
Rice,rawhomepounded 0.21Egghen's 0.10
SQurceo
ConRice,milled 0.06Mutton 0.18 ryptop
cereals
Bengalgramdhal 0.48Liver,sheep 0.36
Almonds
0.24 unavai
Singellyseeds 1.01
Defic
roundnut 0.90
Nia
Charaurce:(34)

168. 709
VITAMINS
Gources
Is
riCogetables.Meatandfishcontainsmallamounts.
mEenledhetherwholeormilled)and
pulsesarerelatively
rcesbut
becauseofthebulk
pood
they
contributemuchofthe
riboflavintoIndian
nsormination
increases
the
ribotlavin
contentof
pulseS
dementia.
In
addition
glossitisand
stomatitis
usually
OcCur
ne
dernmatitisis
bilaterally
symmetricalandis
found
oniy
Onthose
surtacesofthe
body
exposedto
sunlight,
such
as
Oackofthe
hands,lower
legs,faceand
neck.
Mental
changes
mayalso
occur
which
include
depression,
irritability
and
t
natural
SOurcesaremilk,eggs,liver,kidneyand
ulkinwhichtheyare
delirium.
consur
etsals.
The
ribolavin
contentofsome
commonfoods
Oncea
formidableand
widespread
deficiency
disease
among
malnourished
population
subsisting
mainlyonmaize
alets,
pellagrahas
declinedinallpartsofthe
world.
Itis
still
prevalent
in
somepartsof
Western
Asiaand
Southern
Africa
wnerepeople
subsistonmaizeand
littleelse
(38).
While
pellagra
is
historicallya
disease
ofthe
maize-eating
Population,itwas
reportedinIndiainthe
Telangana
area
or
Andhra
Pradeshinsome
segmentsofthe
population
eating
another
cereal
-thatisjowar
(Sorghum
vulgare),
these
people
consuming
very
littleof
milkorother
foodsof
animal
origin.
Studiesby
Gopalanand
others
(39)have
shownthat
amino-acid
imbalance
causedbyan
excessof
leucine
isthe
causeof
pellagrainbothjowarand
maize
eaters.
Excess
of
leucine
appearsto
interfereinthe
conversion
of
tryptopnan
and
cereals.
is
givenin
lable
10.
TABLE10
Dietary
sourcesot
riboflavin
Foodsof
vegetable
Foodsof
animal
origin
mg/100g origin
mg/100g
sets 1.70
Wholecereals
0.10-0.16
Liver,
sheep Milledcereals
0.19
0.03-0.08
Milk
cow's
nle
Egg.hen
0.40
Pulses
0.21-0.32
Ihe
0.14
eafy
vegetables
0.15-0.30
Meat
toniacin.
bource
(34) Prevention
Deticiency
The
most
commonlesion
associated
with
riboflavin
deficiency
isangular
stomatitis,
which
occurs
frequentlyin
malnourishedchildrenandits
prevalenceisusedasanindex
ofthe
stateofnutrition
of
groupsof
children(3).Other
clinicalsigns
suggestive(but
not
specific)
include
cheilosis,
alossitis,
nasolabial
dyssebacia,
etc.
Hypo-riboflavinosis,
evenwhen
severe,seldom
incapacitatesthe
individual,butit
may
have
subtle
functional
effectssuchas
impaired
neuromotorfunction,
woundhealingand
perhaps
increased
susceptibilityto
cataract(37).
Riboflavin
deficiencyalmost
always
occursin
associationwith
deticienciesof
other
B-complexvitaminssuchas
pyridoxine;itisusuallyapartof
a
multiple
deficiency
syndrome.
neurtis
tz
berberi
sed
aAndhta
Prae
stigations
byte
dly
encourtie
condilions
a
Pellagraisa
preventable
disease.
Agood
mixeddiet
containing
milkand/ormeat
is
universally
regarded
asan
essential
partof
preventionand
treatment.
Avoidance
of
total
dependenceonmaizeor
sorghum
isan
important
preventive
measure.
Pellagraisa
diseaseof
poverty.Given
modern
knowledgeand
opportunitiesfor
economic,
agriculturaland
social
development,thereisevery
reasonto
hopethatthis
disease
couldbe
eliminated(3).
Requirement
The
recommended
daily
allowanceis12mgperdayof
energyintake
(11).Forfurther
detailssee
Table28.
gpeopleto
a
amine-richtaxs
andtostop
iskgroupsteg
eribentends
rOveandde
hasbeen
shosn
knowledge
and
sappearancear
Requirement
PYRIDOXINE(B)
Therearenorealbody
storesof
riboflavin.
Daily
requirementis1.96mgper1000kcalof
energyintake(11).
Forfurtherdetailssee
Table28.
Pyridoxine
(vitaminB)
existsinthree
forms
Pyridoxine,
pyridoxaland
pyridoxamine.Itplaysan
importantrolein
the
metabolismof
amino-acids,fatsand
carbohydrate.
Itis
widely
distributedinfoods,e.g.,milk,liver,meat,eggyolk,
fish,
wholegrain
cereals,
Pyridoxine
deficiencyisassociatedwith
peripheral
neuritis.
Riboflavin
deficiency
impairsthe
optimal
utilizationof
pyridoxine.
INH,an
antituberculosisdrug
isa
recognized
antagonist,and
patients
receiving
INHare
providedwitha
supplementof
pyridoxine(10mg/day).
The
requirementsofadultsvarydirectlywithprotein
intake.
Adultsmayneed
2mg/day;during
pregnancyand
lactation,
pyridoxine,
therefore
deficiencyisrare.Forfurtherdetails
see
Table28.
NIACIN(B,)
legumesand
vegetables.
at
30
mg
an
the
urine(09
Utnely
bege
d
also
begu
nt
voming
go
on
long
Niacinornicotinicacid(B,)is
essentialforthe
metabolism
of
carbohydrate,fatandprotein.
Itisalso
essentialforthe
normal
functioningofthe
skin,
intestinaland
nervous
Systems.Thisvitamin
differsfromtheother
vitaminsofthe
5-complexgroupinthatan
essential
aminoacid,
tryptophanservesasits
precursor.
Another
characteristicof
hlacinisthatitisnot
excretedinurineassuch,but
is
metabolizedtoatleast2major
methylated
derivatives
N-methyl-nicotinamideand
N-methyl
pyridones.
2.5
mg/day.
Balanceddietsusuallycontain
Sources
Oas
Tichinniacinand/or
tryptophanareliver,kidney
cat,
poultry,fish,legumesand
groundnut.
Milkisapoor
Ce
ofniacinbutitsproteinsarerichin
tryptophan
which
convertedinthebodyinto
niacin
(about60
mgof
Iophan
isrequiredtoresultin
1mgof
niacin).In
many
In
especiallymaize,niacin
occursin
"bound
formn
PANTOTHENICACID(B)
of
the
B-go
lar
oxidation.
the
integrya
There
isalongstandingevidenceforarelationbetween
pantothenicacidand
adrenal
corticalfunction.Work
indicatesamorespecificrolefor
pantothenicacidinthe
biosynthesisof
corticosteroids(7).Humanbloodnormally
contains
18to35mgofpantothenicacidper100ml,mostly
presentinthecellsas
coenzymeA.Thedailyrequirementis
setat5mg(31).Allfoods
contributetodietaryintake.
About3mgareexcreteddailyinurine.
unavailabletotheconsumer.
sm.
20
COlactor
torie
equired
torte
Deficiency
Characterized
bythree
D's
diarrhoea,
dermatitisandNiacin
deficiency
resultsin
pellagra.The
disease
is

169. 710
NOTRITION
ANDHILALTHH
FOLATE cheese.VitaminB,isnotfoundinfoods
of
yond
Itisalsosynthesizedbybacteriaincolon.Uni
e
o
vitaminB,,isrelativelyheatstable.Liveristhe
Bie
Therecommendednameisfolate,alternativenameis
folacinandtheusualpharmaceuticalpreparationisfolic
acid(19).
like
folic
siteofvitaminB2About
2mgarestored
inliver,
stor
another2mgelsewhereinthebody.These
sufficienttotideoveranydeficiencyforone
ttore
Becauseofthesereserves,deficiencyofvitaminDyea
toberare.
mg
I00g
Folicacidoccursinfoodintwoforms
:
freefolatesand
boundfolates.Thetotalfolatesrepresentboththegroups.In
man,freefolateisrapidlyabsorbed,primarilyfromthe
proximalpartofsmallintestine.Theavailabilityofbound
folateisuncertain.Folicacidplaysaroleinthesynthesisof
thenucleicacids(whichconstitutethechromosomes).Itis
alsoneededforthenormaldevelopmentofbloodcellsinthe
B,appea
Deficiency
Amla
Crtava
VitaminB,deficiency
isassociatedwith
mega
anaemia(perniciousanaemia),demyelinatingnsoblasti
marrow.
urologica
lesionsinthespinalcordandinferti(inanimal
s
Germinated
pulses
Bengal
gram
Crange
Sources
whichisrarelyseeninIndia,Whileclinical
B,isnotmanifested,sub-clinicaldeficiencu
Tomato
Thenamecomesfromthelatinfolia(=leaf)butfoods
suchasliver,meat,dairyproducts,eggs,milk,fruitsand
cerealsareasgooddietarysourcesasleafyvegetables.
Overcookingdestroysmuchoffolicacidandthus
contributestofolatedeficiencyinman.Folatedeficiencyhas
beenreportedinbabiesgivenmilkfoodssubjectedtoheat
sterilization.
existinIndia.Reportsindicatethat
s
thereexistme
orted
to
30percentdeficiencyinadultsandchildreninorethan
ItisnotsurprisingthatbloodlevelsofvitarminR ntry
sincealargeproportionofpopulationdepends"lOu
Source:(3
foodfornutrients(9)
Deticienc
are
peficiency
plant
Requirement
ble
IntakevaluesrecommendedbyICMR
(2020
below(11).Detailedrequirementsareasshownin
Tahle
bruisingo
healing,
anaer
important
defi
mportance3
Deficiency
ufich
Folatedeticiencymayoccursimplyfromapoordiet.Itis
Commonlyfoundinpregnancyandlactation(40)where
requirementsareincreased.Itresultsinmegaloblastic
anaemia,
are
le28.
Perday
a)Normaladults
glossitis,
2.2mcg
+0.25mcg
cheilosis
b)Pregnancy
andgastrointestinal
disturbancessuchasdiarrhoea,distensionandflatulence.
Severefolatedeficiencymaycauseinfertilityoreven
sterility.Thereisalsoevidencethattheadministrationof
folicacidantagonists(e.g.,alcohol,pyrimethamine,and
cotrimoxazole)inearlypregnancymayproduceabortionsor
congenitalmalformations.
Requireme
The
estim
adu
c)Lactation
d)Infants&children
+1.0mcg3
for
2.2mcg
Contains
abbo
VITAMINC
oythe
1CMR
Thelaboratorydiagnosisoffolatedeficiencyisbasedon
measurementofserumandredcellfolateconcentrations,
usuallybymicrobiologicalassay(41).
VitaminC(ascorbicacid)isawater-solublevitamin.Itis
themostsensitiveofallvitaminstoheat.Man,monkey
and
guineapigareperhapstheonlyspeciesknowntoreguire
vitaminCintheirdiet.
More
tha
body,
whic
vital
body
groups
phosphoru
6)
TRACE
bodyinq
ron,
Requirement
Bodystoresoffolatearenotlarge,about5-10mg,and
therefore,folatedeficiencycandevelopquickly.Folicacid
requirementsaregreatestinconditionswherethereisrapid
cellmultiplication,suchasduringgrowthinyoungchildren
andduringpregnancy(41).Folicacidsupplementation
duringpregnancyhasbeenfoundtoincreasethebirth
weightofinfantsanddecreasetheincidenceoflowbirth
weightbabies.IntakevaluesrecommendedbyICMR(2020)
aregiveninTable28.
Functions
VitaminCisapotentantioxidantandhasanimportant
roletoplayintissueoxidation.Itisneededtortheformation
ofcollagen,whichaccountsfor25percentoftotalbody
protein(7).Collagenprovidesasupportingmatrixforthe
bloodvesselsandconnectivetissue,andforbonesand
mangane
vanadiur
thelast
f
NO
KNC
cartilage.ThatexplainswhyinvitaminCdeficiencythis
supportfails,withtheresultthatlocalhaemorrhagesoccur
andthebonesfractureeasily.VitaminC,byreducingferic
irontoferrousiron,facilitatestheabsorptionofironfrom
vegetablefoods.Itinhibitsnitrosamineformationbythe
intestinalmucosa.Otherclaimssuchasprevention
of
commoncoldandprotectionagainstinfectionsarenot
substantiated.
barium,
VITAMINB,,
Only
potassik
withcle
VitaminB,iscomplexorgano-metalliccompoundwitha
cobaltatom.Thepreparationwhichistherapeuticallyused
iscyanocobalmin,whichisrelativelycheap.VitaminB2
cooperateswithfolateinthesynthesisofDNA,sodeficiency
ofeitherleadstomegaloblastosis.VitaminB,,hasaseparate
biochemicalrole,unrelatedtofolate,insynthesisoffatty
acidsinmyelin(19).Thephysiologicalmechanismforits
absorptionrequiresintrinsicfactorfromthestomach,and
thecomplexisabsorbedonlyataspecialsiteintheterminal
ileum
i
the
their
Sources
dietar
Such
ThemaindietarysourcesofvitaminCarefreshfruitsand
greenleafyvegetables.TracesofvitaminCoccurinfresh
meatandfishbutscarcelyincereals.Germinatingpulses
containgoodamounts.Rootsandtuberscontainsmal
amounts.AmlaortheIndiangooseberryisoneoftherichest
sourcesofvitaminCbothinthefreshaswellasinthedry
becau
Besic
prop
ele
nave
veg
Sources
condition.Guavasareanothercheapbutrichsourceotthis
vitamin.Thedietarysourcesofvitamin
Careasgivenin
Table11.
ee
Goodsourcesareliver,kidney,meat,fish,eggs,milkand

170. wwwwww
TABLE11
MINERA
711
Dietary
sourcesofvitamiC
CALCIUM
alcium
isamajor
mineral
element
ofthebody
On8ttues
1.5-2percentofthebody
weightofanadut
an
An
averageadultbody
contains
about
1200got
cacium
ofwhichover98percentisfoundinthebones.he
rount
ofcalciumintheblood
isusuallyabout
10mg/al
There
mg100g
mg/100g
Vegetable
600
Cabbage Thedevelopingfoetus
requiresabout30gof
calcium.
1h
Amla 212
124
Amaranth
uava 63
Caulltlower
99sdynamic
equilibriumbetweenthe
calciumintheblood
andthat
inthe
skeleton;this
equilibrium
is
maintainedo
ne
nteractionofvitamin
D,
parathyroid
hormone,
and
probablycalcitonin,Lime
56
30
Spinach
Oange
28
27
Brinjal
Tomato
12
Oerminated
pulses
y
Bengal
gram
Potatoes 17
Raddish
Functions
16
15
nized
calciumintheplasmahas
manyvital
functions
nciuding
formationofbonesand
teeth,
coagulation
or
Dlood,
contractionof
muscles,
cardiac
action,mk
Pproduction,relayof
electricaland
chemical
messagesthat
arive
atacell's
surface
membranetothe
biochemical
machinery
withinthecell,keepingthe
membranesofcells
intactandinthe
metabolismof
enzymesand
hormones.
it
alsoplaysacrucialroleinthe
transformationoflightto
electrical
impulsesintheretina.
Inshort,the
calcium1on
Controls
many
life
processes
ranging
from
muscle
contractiontocelldivision.
Source
(84)
Deficieneyof
vitamin
Cresultsinscurvy,thesignsof
anaemiaand
akness.Scurvywhichwasoncean
Deficiency
whlch
are
swollenand
or
bleedingintotheskinorjoints,delayedwound
bleedinggums,subcutaneous
bruising
healing.
important
defi
importance(3)
eficiencyisease
isnolongeradiseaseofworld
Requirement
The
estimated
requlirementtorvitaminCis40mgper
dau
for
adultsThenormalbodywhen
fullysaturated
rontainsabout5gofvitaminC.Dailyintakes
recommended
bythe
ICMR(11)areasgiveninTable28.
Sources
Calciumisreadily
availablefrommany
sources.Byfar
thebest
natural
sourcesaremilkand
milk
products,
(e.g.,
cheese,curd,
skimmed
milkandbutter
milk),eggsandfish.
Alitreofcow'smilkprovidesabout
1200mgofcalcium,and
human
milkabout300mg.
Calcium
occursinmilkas
calcium
caseinogenate
whichisreadily
assimilatedbythe
body.The
cheapest
dietary
sourcesaregreenleaty
vegetables,cerealsand
millets.The
limitingfactorinthe
complete
absorptionofcalciumfromgreenleaty
vegetables
(e.g,
spinach,
amaranth)
isthe
presenceofoxalicacidwith
which
calciumformsan
insoluble
compound,
calcium
Oxalatewhich
interfereswiththe
absorptionof
calcium.Most
cerealsare
generous
providersof
calcium,andthe
millet
"ragi"is
particularlyrichin
calcium.Riceisvery
deficientin
calcium(43).The
bioavailabilityof
calciumfromcerealsis
poorbecauseofthe
presenceofphyticacidwhichformsan
insoluble
compound
with
calcium,
calciumphytate.
An
additionalsourceofcalciumisdrinkingwaterwhichmay
provideupto200
mg/day.Somefruits(e.g.
Sitaphal)
containgood
amountsofcalcium.
MINERALS
n.ltis Morethan50chemical
elementsarefoundinthehuman
body,whicharerequiredforgrowth,repairand
regulationof
vitalbodyfunctions.
1Thesecanbe
dividedintothreemajor
groups:(a)
MAJOR
MINERALS:These
include
calcium,
phosphorus,
(6)
TRACE
ELEMENTS:Theseareelements
requiredbythe
bodyinquantitiesoflessthanafew
milligramsperday,e.g.
iron,iodine,fluorine,zinc,
coppercobalt,
chromium,
manganese,molybdenum,
selenium,
nickel,tin,
siliconand
vanadium(41),Manymorehavebeenaddedtothelistin
thelastfewyears;and
(c)TRACE
CONTAMINANTS WITH
NO
KNOWNFUNCTION These
includelead,
mercury,
barium,boron,andaluminium.
and
equire
Sodium,
potassium
and
magnesium;
ortant
mation
|body
forthe
and
y
this
OCcur
gfernic
nfrom
he
Onlyafewmineralelements(e.g.,
calcium,
phosphorus,
poassium,sodium,iron,
fluorine,
iodine)are
associated
WInclearlyrecognizableclinicalsituations
inman.For
none
e
other
elementsdoweknowwithany
certaintyfor
r
metabolicroles,andmuchlessthe
clinicaleffectsof
ietary
insufficiency(42).The
bio-availabilityofminerals
as
ironandzincmaybelowinatotal
vegetariandiet
R
Othe
presenceof
substancessuchasphyticacid
,largeamountsofdietary
fibremay
interferewith
el
absorption.Manisnot
likelyto
sufferfrom
trace
nt
deficienciesaslongasheis
omnivorous.
Surveys
Absorption
Overall,about20-30percentofdietary
calciumis
normally
absorbed.
Absorptionofcalciumisenhancedby
vitamin
Dand
decreasedbythe
presenceofphytates,
oxalatesandfattyacidsinthediet.
Calcium
absorptionis
regulatedtosome
extentbythebody'sneeds.
by
tion
are
no
Uls
and
in
tresh
Deficiency
nave
Own
thatmineral
deficienciesareno
greater
among
7
pulses
nsimall
erichest
the
dry
Noclear-cut
diseaseduetocalcium
deficiencyhasever
been
observed,
evenunder
conditionsoflowintake(44).It
hasbeen
establishedthat
iftheintakeofvitaminDis
adequate,the
problemsofricketsand
osteomalaciadonot
arise
evenwithlowcalciumintake.Ontheotherhand,no
deleterious
effectshavebeen
observedinmanasaresultof
prolonged
intakesoflarge
amountsofdietary
calcium,
neitherhaveanybenetitsbeen
demonstrated.
vegetarians
thanam
determined
Traceelements
should
notbe
used
as
non-vegetarians.
Infact,
man's
e
fthis
givenn
determineae
elementshasnotyet
been
precisely
dietary
supplements,
njurious
effects.
Since
excessive
amounts
canhave

171. 712
NUTRITIONAND
HEALTH
attributedto
magnesium
deticiencyareirritahit.
hyper-reflexiaand
occasionally
are
estimated
tobeabout44
detailssee
Table28.
ility,
440mg/dayforadults
ekany
hypo-reflexia.equirements
e
total
25
m
Requirement
Adaily
intakeof
1,000mgof
calciumhas
been
suggested
for
adults
whichis
1.5
times
higher
than
earlier
recommendation
(11).
The
physiological
requirements
are
higher
in
children,
expectantand
nursing
mothers.
Intake
values
recommendedby
1CMR(11)areas
givenin
Table28.
ar
roues
of
whereve
(11).
For
pattrolgical
ic
ulcer);
(
IRON
Hich
may
OE
p
Jronisofgreat
importance
inhumannutrition,Th
human
body
contains
between3-4gofiron,of
uhi
adult
60-70per
centis
presentintheblood(HbiOOut
circulatingiron,andthe
rest(1to1.5
g)as
storas
Eachgramof
haemoglobin
containsabout3.34
maofOnPHOSPHORUS
SWeal
a
at
adaitional
eASe
the
Phosphorusis
essentialforthe
formationof
bonesand
teeth.
Itplaysan
important
partinall
metabolisms.
Anadult
human
body
contains
about
400-700
gof
phosphorus
as
phosphates,
mostof
this
occursin
bonesand
teeth.
Phosphorusis
widely
distributedin
foodstuffs;its
deficiency
rarely
occurs.
Alarge
partof
phosphorus
presentin
vegetable
foods
occursin
combination
with
phytinand
is
availabletothe
body
onlytothe
extentof40-60
percent.
Phosphorus
requirements
have
notbeen
specifically
consideredby
FAO/WHO
Committees,butother
groupsof
expertshave
suggestedthat
phosphorus
intake
shouldbeat
leastequalto
calcium
intakesinmostage
groups,
exceptin
infancy
wheretheratio
suggestedis1:1.5(9).
dspreaa
use
Functions
ng
tion,
catecholamine
metabolism.Lack
ofirondirectlyaffectsthe
Ironis
necessaryformanyfunctionsinthebodyinchudi
formationof
haemoglobin,braindevelopmentand
functior
regulationofbody
temperature,muscleactivity,
and
ron
defics
hree
st
Edse
ner
immune
system;itdiminishesthenumberofT-cellsand
th
productionofantibodies.Besides
haemoglobin,ironis
componentofmyoglobin,the
cytochromes,catalase
and
a
certain
enzymesystems.ronisessentialforbinding
oxygen
tothebloodcells.Thecentralfunctionofironis"oxygen
ntetmedia
SODIUM
transport",andcellrespiration.
Sores
are
5
Tecogn
Sodiumisfoundinallbody
fluids.Theadulthumanbody
containsabout100gofsodiumion.
Sodium
occursinmany
foods,andisalsoaddedtofoodduring
cookingintheform
of
sodium
chloride.
Sodiumislostfromthebodythrough
urineand
sweat;that
which
ispassedoutinurineis
regulatedbythekidneybutthat
whichislostbysweatingis
not
controlled.
Depletionofsodium
chloride
causes
muscular
cramps.The
requirementofsodium
chloride
dependsupon
climate,
occupationand
physicalactivity.
Adultrequirementisabout5gperday.Astrongrelationship
between
hypertensionanddietarysaltintakehasbeen
observedandintakeofmorethan10gofsaltperdayis
consideredtohave
definitivetendencytoraiseblood
pressure(9).
Sources
Therearetwoformsofiron,haem-ironandnon-haem
iron.
Haem-ironisbetterabsorbedthannon-haemiron.
Foodsrichinhaem-iron
areliver,meat,poultryandfish.
Theyarenotonlyimportat
sourcesofreadilyavailableiron
buttheyalsopromotetheabsorptionofnon-haemironin
plantfoodseatenatthesametime(47).Theironcontentof
milkislowinallmammalianspecies.Ironcontentofbreast
milkaverageslessthan
Foodscontainingnon-haemironarethoseofvegetable
origin,e.g.,cereals,greenleatyvegetables,
legumes,nuts,
oilseeds,jaggeryanddriedfruits.Theyareimportant
sourcesofironinthedietsofalargemajorityofIndian
people.The
bioavailabilityofnon-haemironispoorowing
tothe
presenceofphytates,
phosphatesanddietaryfibrewhichinterferewithiron
absorption.Otherfoodswhichinhibitiron
absorptionare
milk,eggsandtea(48).Thendian
dietwhichis
predominantlyvegetariancontainslargeamountsofthese
inhibitors,e.g.,phytatesinbran,phosphatesineggyolk,
tannininteaandoxalatesinvegetables.Insomeareas,
signiticantamountsofironmaybederivedfromcookingin
ageis
hird
sta
TeCTeas
Lueto
The
whICO
).2mg/dl,anditiswellutilized.
POTASSIUM
oxalates,
carbonates,
Theadulthumanbodycontainsabout250gof
potassium.
Potassiumoccurswidelyinfoodstuffs,sothereis
littlelikelihoodofits
deficiency.Potassiumisvasoactive,
increasesbloodflowandsustains
metabolicneedsofthe
tissue.
Potassiumisreleasedbyendothelialcells.Potassium
supplementslowerbloodpressure,althoughtheresponseis
slow.Muchoftheinformationregardingpotassiumand
bloodpressureisinrelationtodietarysodium.Highdietary
sodium,lowdietarypotassiumhavebeenimplicatedinthe
aetiologyofhypertensionasevidencedby
epidemiological
clinicalstudies(9).
ironvessels.
Absorption
Ironismostlyabsorbedfromduodenumanduppersmall
intestineintheferrousstate,accordingtobodyneeds.The
rateofironabsorptionisinfluencedbyagreatmany
tactors
likeironreservesofthesubjects,thepresenceofinhibitors
(e.g,phosphates),andpromoters(e.g.,ascorbicacidand
ascorbicacid-richfoods)ofironabsorption,and
disordersot
duodenumandjejunum(e.g.,coeliacdisease,tropica
sprue).Ironabsorptionisgreaterwhenthereisanincreasea
demandforiron,asforexampleduring
pregnancy.rO
absorptionfromhabitualIndiandietsislessthan5percent,
thebioavailabilitybeingpoor.
Theidealdesirablesodium:potassiumratiointhedietis
1:1(inmmol).
MAGNESIUM
Magnesiumisaconstituentofbones,andispresentinall
bodycells.Humanadultbodycontainsabout25gof
magnesiumofwhichabouthalfisfoundintheskeleton.It
appearsthatmagnesiumisessentialforthenormal
metabolismofcalciumandpotassium(45).Magnesium
deticiencymayoccurinchronicalcoholics,cirrhosisofliver,
toxemiasofpregnancy,protein-energymalnutritionand
malabsoptionsyndrome(46).Theprincipalclinicalfeatures
Theabsorbedironistransportedasplasma
ferrifinand
storedinliver,spleen,
characteristicfeatureofiron
metabolismis
conservati0n
Whenredcellsarebrokendown,theliberatediron
reutilizedintheformationofnewredcells.
bone
marrowand
kidney.
The

172. 715
OTHER
TRACE
ELEMENTS
disease,perniciousanaemia,thalassaemiaand
as
ialinfarction.Zincdenciency
1scommoninchildren
mdevelopingcountriesauetolackofintakeofanimal
Selenium
Littleattentionhadbeengivenearliertoselenium
in
numannutrition.Thefirstreportthat
seleniumdeticiency
nayoccurinmanappearedin1961,and
asimilarreport
n
elenium
administrationto
childrenwith
kwashiorkor
esuitedin
significantweightincrease.Studiesindicate
that
numanseleniumdeficiencymayoccurinprotein-eneroy
malnutrition(66).Selenium
deficiencyespeciallywhen
Combinedwithvitamin
Edeficiency,reducesantiboay
production(68).40ug/dayisrecommended
intake
or
selenium(11).
from
food,highdietary
pnytatecontent,inadequatefoodintake
and
Toincreasedfaecallossesduringdiarrhoea.Zinc
supplementationincombinationwithoralrehydration
iherapyhasbeenshoWn
tosignificantlyreducetheduratil
severityofacuteandperSIstentdiarrhoeaandto
increasesurvivalinanumberoIrandomizedcontroltrials.
Adeauatezincintake
1Sessentlal
1ormaintainingtheintegrity
ofimmune
system.Zincaffectsmultipleaspectsofthe
immune
system,romtneDarrier
oftheskinto
onulationwithinIymphocytes.everematernalzinc
deficiencyhasbeenassoclateawithspontaneousabortion
andcongenitalmallormaions
lkeanencephaly.Milder
forms
ofzincdeficiencyhasbeenassociatedwithlowbirth
weight,intrauterinegrowthretardationandpreterm
delivery.Severalstudieshaveindicatedthatzinc
supplementationmayreducethe
incidenceofclinicalattacks
ofmalariainchildren.Zincplaysanimportantroleas
antioxidantagent(65).Thesereportssuggestthatzinc
deficiencymaynotbe
uncommoninman(63).Zincis
widelydistributedinfoodstuffs,bothanimalandvegetable
butthebioavailabilityofzincinvegetablefoods
islow
Animalfoodssuchasmeat,milkandfisharedependable
sOurces.Suggesteddailyintakeforadults
is17mgperday
ormen,13.2mgperdaytorwomen,10mgperdaytor
childrenand
5mgforinfants,RefertoTable28fordetails.
Growingchildrenandpregnantandlactatingwomenneed
more.Mosthumandietsprovidetheseamounts.
gene
Molybdenum
Excessabsorptionofmolybdenumhasbeen
shoWnto
producebonydeformities.Ontheotherhand,deficiency
or
molybdenum
isassociatedwithmouthandoesophageal
cancer(67).
Dietaryantioxidants
(9)
Antioxidantsaresubstanceswhicharebothnutrients,viz.
VitaminsE,C,B-carotene,selenium,andnon-nutrients,
VIz.
plant
1sothiocyanates,Cafteic,ferrulic,gallicandellagicacids,
Some
enzymeslikesuperoxidedismutaseandcatalase
Superoxidesmutase.Iheseantioxidantsreducetheadverse
effectsofreactiveoxygenspecies(ROS)andnitrogen
specieswhicharegeneratedduringphysiologicalor
pathologicalconditionsandresultinoxidantdamage.
Literature
isrepletewithevidencethatageingandseveral
diet/nutrientrelatedchronicdisordersareduetochronic
benzyl
phenols,tlavonoids,
Coumarins,
exposuretoROS.
Itiswellestablishedthatvegetables,fruits,
legumes,spices,beveragessuchasteaandwine,and
cerealsareexcellent
sourcesofAO,howeverscientific
evidencefortheirprotectiverole
isavailableonlyfor
vegetablesandfruitsinseveralchronicdisorders.Noneof
therandomizedclinicaltrialsconductedsotarwithnutrient
AOsupplementshasdemonstrated
asigniticantbenefitin
communitytrialsbarringoneortwomajortrialsinhigh-risk
populations.
Copper
Iheamountofcopperinanadultbody
isestimatedtobe
Derween100-150mg.Copper
iswidelydistributedin
narure.Evenpoordietsprovideenoughcoppertorhuman
eeds.Deticiencyorexcessofthiselement
1sveryrare.
ypocupremiaoccursinpatientswithnephrosis,
Wilsonns
ISeaseandprotein-energymalnutritionandinintantsfed
i1Ongperiodsexclusivelyoncow'smilk.Neutropenia
is
Dest
documentedabnormalityofcopperdeficiency.
ypercupremiamayreflectexcessiveintakewhicnmay
u
romeatingfoodpreparedincoppercookingvesse15,
maybeassociatedwithseveralacuteandchronic
ons
(leukaemia,Hodgkin'sdisease,
severeanaema
haemochromatosis,
Experimentalstudieshaveamplyindicatedthatboth
pro-oxidantandAOhaveafundamentalroleinpathogenesis
ofdiseases.Reactiveoxygenspecies(ROS)damagethe
bio-moleculessuch
asDNA,protein,carbohydratesand
lipids,andaffectthe
enzymeprocessesandgenetic
intarctioonand
dl
odism(66).Estimatedcopper
requirementfor.nacie
OxIdatton
productsof
bio-molecules
daultsisabout2.0mgperday
myocardial
accumulatewithage.ROScanbederivedfroman
enviornmentalsourcealso.Thereareseveralendogenous
and
exogenoussourcesofROS,whichplayanimportantrole
indiseasessuchascardiovascular,cancer,cataract,diabetes
neuro-degenerativedisordersandage-relatedmasculopathy
Chronicinfectionsaggravatethedamage.Further,research
inthisfieldhashighlightedthemechanisticdetailsaboutth
roleofantioxidantsinmitigatingthedamage.
Freeradicalsproducedduringtissuemetabolisman
theirconsequentdamage
arereducedbynutrier
ntioxidants.Theantioxidants,particularlyvitaminE,
C
co-enzymeand
giutathioneseemtoworkinconcert
b
recyclingeachother.
Inhealthysubjects,thedietar9antioxidantsfrom
balanceddietwithadequatefruitSandvegetablesrangin
from500-600
gm/dwillprobablybe
enoughtotakecare
Oxidantdamageandrepaircellularandtissuedefect
However,certain
groupsopopulations
likepre-matu
infants,smokersalconolcs,
andthoseexposed
environmentalpoilutantsinciudingcarcinogens,individua
Cobalt
nnyestablishedfunctionofcobaltinthehumanisas
apartofthevitaminB,molecule,wihaltdeficiency
pretormed.Thereisnoevidenceasye
cobaltiodine
tatio
in#ecently
cobalt
deficiencyandcobaltiodine
nman
(10).Recently
Coo
Droducego
for
thetirstIt
isS
5O1haveshowntoproducegoitreinhumans
ggestedthatcobaltmaybenecessar
gland
Ulzation
(67).Cobaltmayinteractwithiodineandaffect
itShormoneproduction.i.e.,captureofiodinebythe
for
stage
of
zation(10).
Chromium
ent
intowont
ofchromiumissmall,lessthen6
mng
nchromiumisbasedonthe
occurrenceof
Sualglucose
tolerance
curvesthatareresponsive
to
nterest
chromi
Chromium.Thusthereissuggestive
evidencetnat
lin
funs
aroleinrelationtocarbohydrate
ana
5ulinfunction
(10)

173. TABLE22
722 as
REFERENCE
BODY
WEIGHTS(9)
Age.
gehderand
body
weighit
largely
determinethe
nulritio1al
requiementofan
individual.Body
weightsand
heights
oafchildrernreflecttheirstateof
health,
mutritionand
growthrate,
while
weightand
heightsof
adults
represent
whatcanbe
attainedbyan
individualwithnormal
growth
Anthropometric
measurementsof
infantsand
childrenof
wellto-do
familieshaving
accesstogood
health
careand
no
nutritional
constraintsare
usuallytreatedas
reference
values.The
purposeof
recommendingnutrient
requirements
isfohelp
atfaining
these
anthropometric
reference
standards
Category Bodyweghts
teg
hgeGrop
18
years
65.0
Men
>18years
550
58
85
117
Women
0-6months
tire
irnfants 6-12months
1-3years
Children
4-6years 183
7-9years 253
wHOstandard
weightsandheightsofinfants
and
pre-school
children
Boys
10-12years 349
WorldHealth
Organizationhas
recently
published
multi-
cenfre
growth
reference
standardsfor0-60monthboysand
girls,basedonstudiescarried
outamong
predominantly
exclusively
breast-fed
childreninsix
countriesviz.,USA,
Brazil,Ghana,
Norway,Omanand
India.Themedian
weightsofinfantsand
pre-school
children(1-3years)
can
betakenasreferencevaluesforIndian
children
Girls
10-12years 36.4
Boys
13-15years 50.5 S
Girls
13-15years 49.6
Boys
16-18years 644
Girls
16-18years 55.7
Source:(11)
ReferenceIndianadultmanand
woman
"Reference
manisaged
between19-39
yearsand
weighs65kgwithaheightof1.77metreandaBMIof
20.75;isfreefromdiseaseand
physicallyfitforactivework.
Oneach
workingday,heisengagedin8hoursof
occupationwhichusuallyinvolvesmoderate
activity;while
whennotatworkhespends8hoursinbed,4-6hoursin
sittingandmovingabout,2hoursinwalkingandinactive
recreationorhouseholdduties.
ENERGY
Energyisaprimerequisiteforbodyfunctionandgrout
Whenachild'sintakeoffoodtalsbelowastandae
reference,growthslows,andiflowlevelsofintakenere
adultstaturewillbereduced.Similarly,ifadultsfailto
meot
theirfoodrequirementstheyloseweight.Thismayleadto
reducedabilitytowork,toresistintection,andweakened
willtoenjoythenormalsatistactionoflife.Thisunderlio
theneedforanadequateintakeoffoodwhichisthe
sourro
ofallenergy.
"Reference
womanisagedbetween19-39years,non
pregnantnon-lactating
(NPNL)andweighs55kgwithaheight
of1.62metreandaBMIof20.95,isfreefromdiseaseand
physically
fitforactivework.Oneachworkingdaysheis
engagedin8hoursofoccupation,whichusuallyinvolves
moderateactivity,whilewhennotatworkshespends8hours
inbed,4-6hoursinsittingandmovingabout,2hoursin
walkingandinactiverecreationorhouseholdduties.
Measurement
ofenergy
Theenergyvalueoffoodshaslongbeenexpressedin
termsofthekilocalorie(kcal).Thekilocalorieisgenerally
expressedas"Caloriewrittenwithacapital"C"(74).This
hasbeenreplacedbythe"jouleexpressedasJ,whichhas
beenacceptedinternationally.Theseunitsaredefinedas
follows
infants
Theaverageofbirthweightandbodyweightat6months
isusedforcomputingthereferencebodyweightforinfants
0-6monthsofage.For6-12months,anaverageofbody
weightat6monthsandat12monthsistakenfor
computation
Joule,aphysicalunitofenergy,isdetinedastheenergy
requiredtomove
1kgofmassby
1metrebyaforceof
1Newtonactingonit(OneNewtonistheforceneededto
accelerateonekgmassby
1metrepersec
).
Kilocalorie(kcal)isdefinedastheheatrequiredtoraise
thetemperatureofonekgofwaterby1°Cfrom14.5°Cto
15.5°C.Theunitkcalisstillpopularlyused.
Children
Forchildren1-3yearsofage,anaverageofbodyweight
at18months,30months,42monthsofWHOmedian
weightistaken(asmentionedabove).
Thereferencebodyweightforchildrenof4-6yearsare
obtainedbyaveragingthebodyweightof44+,5+and
6+years.Similarlyforotheragegroupsalsothereference
bodyweightswereobtainedfromthe95thcentilevalueof
bodyweightsofruralIndia.
Therelationshipbetweenthetwounitsofenergyisas
follows:
1kcal=4.184
KJ(KiloJoule)
11KJ 0.239kcal
1000kcal 4184KJ=4.18MJ(MegaJoule)
Adults
1MJ =239kcal
Theaverageofvaluesforagecategoryof18-19,20-24,
and25-29yearswasusedforcomputingthereference
weightsforadultmanandwoman.
Referencemanandwoman
Thesummaryofreferencebodyweightsforpopulationin
specifiedagegroupsisasshowninTable22.
Energyintakerecommendationsare
formulatedfor
a
reterencemananda"referencewoman"whoseprotles
aredescribed,andthennecessaryadjustmentsaremadeto

174. ENERGY 723
fromthestandardreference.This
devisedbytheFAOCommitteeon
whodeviate TABLE23
Subyecis
edure
wasfirst
proc
auirementsin1950(75)andhasbeeninuseever
ergyrequirernent(kcatd)asproprsed
byIMR2021
ICMR
2020
calori
since.
ICMR
Difference
2010
Age Category
group
2320 -210
Energy
requirements
Sedentarywork
2110
20
The
energyrequirementofanindividualisdefinedas
foodthatbalancesenergy
individualhasabodysizeand
2710
2730
AdultMen Moderatework
that
levelof
diture,whenthe
enositionandlevelofphysicalactivity,consistentwith
n-termgoodhealth,alsoallowingformaintenanceof
ronomicallyessentialandsociallydesirableactivity.In
Fhildrenandpregnantandlactatingwomen,itincludesthe
nergyneeds
associated
cocretionofmilkatratesconsistentwithgoodhealth(9).
Thetwostandarddeviationvalueisnotaddedtothe
averagerequirement.Ihisisbecausetheenergyintakeand
expenditureofanindividualarefinelybalanced,andany
surplusenergyconsumptionwillbestoredasfatanda
continuousexcessofintakewillleadtoobesity(9).Adults
andevengrowingchildrenareknowntoadapteitherintake
tosuittheiroutput,oroutputtosuitintakeoveraverywide
range.Wedonothaveaproperunderstandingofthelower
limitofadaption.
ofenergintakefrom
3490 -20
Heavywork 3470
1660 1900 -240
Sedentarywork
2130 2230 -100
Moderatework
2720 2850 -130
Heavywork
withthedepositionoftissuesor
AdultWomen
350
Pregnant +350
Lactating(0-6m)+600+600
+520Lactating(7-12m)+520
0-6months 550 520 +30
Infants
6-12months 670 670
1-3y 1010 1060 50
4-6y 1360 1350 +10
Children
i 7-9y 1700 1690
Boys 10-12y 2220 2190 +30
Factorsaffectingenergyrequirements
Energyrequirementsvaryfromonepersontoanother
dependinguponinter-relatedvariablesactinginacomplex
way,suchasage,sex,workingcondition,bodycomposition,
physicalactivity,physiologicalstateetc.Allthesefactors
leadtodifferencesinfoodintake.
2010 +50
|Girlsatin
10-12y
Boys9us13-15y
13-15y
2060
2860 2750 +110
2400 2330 +70
Girls
Boys
Girls
16-18y 3320 3020 +300
16-18y 25002440 +60
Currently,itisrecommendedthatenergyrequirement
mustbeassessedintermsofenergyexpenditureratherthan
intermsofenergyintake.
Itisalogicalapproach,whereone
canspecifytheenergyrequirementsintermsofenergy
Ourputforproductiveworkandleisureactivityofadultsand
nsSuedepositionininfants,childrenandduringpregnancy
andmilksecretionduringlactation.Thisdoesimplythat
nereisaneedtospecifyanappropriatebodyweightot
individual
aswellasthequantumofphysicalactivitythatis
considered
'desirable'forthesameindividual(11).
Source:(11)
(+350kcaldailythroughoutpregnancy)andlactation
(+600kcaldailyduringthefirst6months,and+520kcals
dailyduringthenext6months)overandabovetheirnormal
requirements.Thisistoprovidefortheextraenergyneeds
associatedwiththedepositionoftissuesorthesecretionof
milkatratesconsistentwithgoodhealth(11).
(b)Children:Becauseoftheirrapidgrowthrate,young
childrenrequireproportionatelymoreenergyforeach
kilogramofbodyweightthanadults(seeTable28).
Aproblemthatarisesisinrecommendingintakesin
communitieswherealargenumberofchildrenare
underweightbecauseofmalnutrition.Inordertoprovidefor
"catch-upgrowth"duringchildhood,intakesshouldbe
basedonageratherthanweightwherepractical(77).The
ICMRstandardsarebasedonage,andnotonbodyweight
(exceptduringthefirstyearoflife).
Childrenabovetheageof13yearsneedasmuchenergy
asadults.Thisisbecausetheyshowagooddealofphysical
activity,almostequaltohardworkbyadults.Thisisalso
the
agewhenpubertysetsinandthereisaspurtingrowthand
an
increaseinmetabolicrate.Thisfactshouldbe
borne
in
mindwhenplanningdietariesforchildren.
(c)Adults:Theenergyrequirementsdecreasewithage
becauseofafallinBMRandadecreaseinphysicalactivity
inmostpersons.Ingeneral,thereisa2percentdeclineof
restingmetabolismforeachdecadeforadults(31).The
FAO/WHOcommitteesuggestedthataftertheageof
40vears,requirementsshouldbereducedby5percentper
eachdecadeuntiltheageof60,andby10percent
foreach
decadethereafter(76).w
Iherearethreeimportanttermswhiledefiningenergy
Denditureusingphysicalactivityestimations.Theseare
ycal
ActivityRatio(PAR),PhysicalActivityLevel(PAL)
tal
EnergyExpenditure(TEE).Thephysicalactivity
AR
isexpressedastheratiooftheenergycostofan
maalactivityperminutetothecostofthebasal
metabolic
rate(BMR)perminute.
Physical
Activity
Ratio
(PAR)
Energycostofanactivity
perminute
bodys
henum
sizes.
sisbecausethesecovariates
appearinboth
Energycostofbasalmetabolism
perminute
The
PAR
isunit-less,andthedistinctadvantageof
relatestoitsuseforbothsexes,atallagesandatall
umerator
and ominatorandcancelout(11):
Table
23shows
the
2020,
for
ariousagegroups.fasssvi
alues
roergyexpenditureofanactivityintermsofPAR
nergyrequirementas,proposedby
Vulnerable
groups
aPregnant
andlactatingTequirements mothers,The
energy
OWomenareincreased.by
pregnancy

175. Theaniroacit
forcheicales
bvetween50and66fortarcves,andF0ant
foods(69)
(iNetprotein
utilization(NP
724
eceminantly
plant
foodbased,
are
carbohydrate,ta,
Patein
and
dietary
fibre.They
suppy
energyattte
4kcal/a
9kcal/g
4kcal/g
2kcal/g
the
main
sourceof
energyin
Indiandiets,which
are
digestibilitycoefficientandbiologicalvatue
100(8).TheNPUgivesamorecompiete
proteinqualitythantheaminoacid
senre
fsi
methodthatrequiresspeciallaboratoryfacilitten
followin9rates
Protein
sortyNitrogenretainedbythebodyFat
NPU
Carbohydrate Nitrogenintake
Dietaryfibreformsan
indigestibleand
important
componentofplantfoodand
wasneverearlier
considered
assourceof
energy.Thesedietary
fibres(solubleand
insoluble)
undergo
fermentationinthecolonandyieldshort
chainfattyacids,suchasbutyric,proplonicandaceticacids
whichareutilizedasasourceof
energybythecoloncells
andbytheliver.Hencetheyareknowntoyieldenergyfrom
fermentablefibreandnoenergyfrom
non-fermentablefibre.
Inconventional
foods,70percentotfibre
isfermentable.
Ingeneral,
energyconversionfactorforfibreistakena5
2.0kcal/g.
Hitherto,dietaryfibrewasnotdetermined
directlyasasourceofenergyand
there
isaneedto
recalculateenergyvieldofvariousfoodsonthebasisoftheir
revisedcontentof
carbohydrates,proteins,fatanddietary
fibre(9).
Dietaryfibre
Incalculatingproteinquality,
1gramof
assumedtobeequivalentto6.25gofN
TheproteinrequirementvarieswiththeNPU
protein.
IftheNPUislowtheproteinrequirementan
andviceversa.TheNPUoftheproteinofIndiandiet
between50and80
of
protei
in
(b)PROTEINQUANTITY
TheproteincontentofmanyIndianfoods
has
determinedandpublishedinfoodcomposition
tatiles
wayofevaluatingfoodsassourceofproteinistodetere
whatpercentoftheirenergyvalueissuppliedb
proteincontent.Thisisknownas
Protein-EnergyRati.
(PEratioorpercentage).
alth
their
The
1CMS
gran
atio
Themainsourceofenergyindietsiscarbohydrates
derivedlargelyfromcereals.Thesecerealsconstituteabout
80percentofourdietandprovide50-80percentofdaily
energyintake.However,energycontributionfromdiets
variesverywidely.ThosebelongingtoloWincomegroup
haveonly5percenttatintheirdiet,whereasaffluent
familiesderiveashighas30percentoftheirdietaryenergy
fromfat.Mostfamiliesderive10-12percentofenergyfrom
Energyfromprotein
PE
percent x100
Totalenergyindiet
Thisconceptisusefulbecauseinmanypopulationgrou
adequatedietisnotconsumedtomeetenergy
eds
resultinginenergydeficits.Theratio
ofproteinrequirement
expressedastheratioofproteincaloriestothe
enerm
requirementisasgiveninTable24.
Tne
pre
proteins(9).
gnancs
Zgulteme
trimeNutritionalindividuality
Innormalindividualsatallagesandofbothsexes,there
isalargevariationinenergyintakebutthereasonsforthis
widerangeofnutritionalrequirementsarenotknown.The
conceptofnutritionalindividualityneedstobestressed,and
itsneglectmayresultintheover-feedingofsomewhose
needshappentobelessthanthe"averagestandard
requirement"(78).
TABLE24
Protein-energyratiofordifterentagegroups(2020
gper
Protein
requirementrequirement
g/kg/d
Group Energy PEratio
of
requirementkcalkg/d
Pre-schoolchildrenb
1-5years 0.95 79 4.8
Schoolchildren
6-10years
PROTEIN
0.91 68 5.4
Proteinrequirementsvaryfromindividualtoindividual.
Apartfromage,sexandotherphysiologicalvariables,
factorslikeinfection,worm
disturbancesandstresssituationscanaffectapersons
proteinrequirement.
Adolescents
11-17years(Boys)
11-17years(Girls)
088
0.86infestation,emotional
Adults
Men(Sedentary)
Women(Sedentary)
0.83 32 10.4
Assessmentofprotein 0.83 30 11.1
(a)PROTEINQUALITY
Men(Moderateactive) ).83 39 8.5
Women
Thequalityofaproteinisassessedbycomparisontothe
"referenceprotein"whichisusuallyeggprotein.Two
methodsofassessmentofproteinqualityneedsmention
(Moderateactive) 0.83 37 9.0
(i)Aminoacidscore
:Itisameasureoftheconcentration
ofeachessentialaminoacidinthetestproteinexpressedas
apercentageofthataminoacidinthereferenceprotein.
PERatio=ProteinEnergyratio;thesevaluesrefertothe
requirement
aSaferequirementofhigh-qualityprotein
bAssumingmoderatelyactivechildrenandadolescents
mgofaminoacidpergoftestprotein Source:(11)
Aminoacidscore= X100
mgofthesameaminoacid
pergofreferenceprotein
Theprotein-energypercentagevalueofsome
commony
usedfoodsisasshowninTable25.
8

176. 725
PROTE
TABLE25
TABLE26
Relativeproteinvalueof
somefoods
nercentoftotalenergýsuppliedbyprotein
Essentialaminoacid
(EAA)reguirenents
Adiut
FAOWHO/UNU2007
mggprotein
15
Aminoacid
mg/kg/d
Nutrientsper100g Energyfromproteins
10
Protein Actual Histidine 30
PE% 20
39
Food kcal
9 (kcal) Isoleucine 59
Leucine 45
3020.0
3.2
21.0
100 80 80
Lysine 16
Fish
Milk
(cow)
Dhal
67
13 20
Methionine
10
6
350
84 24
Cysteine
4
22
7.0 28 8 15
350
100
Methionine+Cysteine
Threonine
23
Rice
1.6
38
Potato
1.0 4 4 25
Phenylalanine+Tyrosine
Tryptophan
100
6Banana
0.7 2 4
160 39
lapioca
26
Valine 277
Ifthe
PEislessthan4percent,thesubjectwillbeunable
to
eatenoughtosatistyprotein
requirements.Itis
recommendedthatproteinshouldaccountforapproximately
10-12percentofthetotaldailyenergyintake.es
184
TotalEAA
0.66g/kgd
0.83g/kg/d
Totalprotein
Safelevelofprotein
(Meant1,96xSD)
Source:(11)
Dietaryintakes
Itiscustomarytoexpressrequirement
intermsofgrams
perkgofbodyweight.Thisprincipleappliestoallage
groups,althoughabsoluteadditionsinunitsofgramsof
proteinperdayaremadeforpregnancyandlactation.
The
1CMRExpertGroup(11)suggestedanintakeof
0.88gramofproteinperkgofbodyweightforadultmales
andfemales,assumingaNPUof65forthedietaryprotein.
Table28givestheproteinintakesforindividualsofdifferent
agesandphysiologicalstates.
aminoacidsarepresentinthediet.TherequirementofEAA
decreasessharplyasoneadvancesinage.Thequalityofthe
dietisfarmorecriticalfortheinfantthanfortheadult.
Newtissuescannotbeformedunlessalltheessential
FAT
Thedailyrequirementoffatisnotknownwithcertainty.
Duringinfancy,fatscontributetoalittleover50percentofthe
totalenergyintake.Thisscalesdowntoabout20percentin
adulthood.TheICMRExpertGroup(2020)has
recommended
anintakeof20percentofthetotalenergyintakeasfat,of
whichatleast50percentoffatintakeshouldconsistof
vegetableoilsrichinessentialfattyacids.Therequirementof
essentialfattyacids
rangesfrom3percentenergyintaketo
5.7percentofenergyintakeinyoungchildren.
SuggestedlevelsoffatintakeareasgiveninTable27.
Vulnerablegroups
Theproteinrequirementsofwomenareincreasedduring
pregnancy.For10kggestationalweightgainthe
requirementincreasesby1,9.5and22g/dayin1st,2ndand
rd
trimestersrespectively;andduringlactationbyabout
9
perday(during0to6months),overandabovetheir
normalrequirements.
TABLE27
Youngchildren(0to6years)require
proportionately
noreproteinforeachkilogramofbodyweightthanadults.
RecommendationsfordietaryfatintakeforIndians(2020)
Visiblefat
Fatfrom
Age/Gender/
Physical
Physiologicalactivity
Minimum
leveloffoodsother
Totalfatthanvisible%E g/p/d
(%E) fats,oE
Iheyaremorevulnerabletomalnutrition.
made
has
TheICMR ExpertGroup
(11) groups
ecommendationsfortheelderly.Itseemsreasonableto
umethattherequirementoftheagedarenotlessthan
natforyoungadults,asshowninTable31.
25
Sedentary
AdultMan
30
40
20 10 10
Moderate
Heavy
Allestimatesofprotein
requirementarevalidonlywhen
nergyrequirementsarefullymet.fthetotal
energy
dKe
isinadequatesomedietaryprotein
willbedivertedto
wae
energy.Itisnowacceptedthattherearenobody
n
storeswhichcanbe
filledupbyahighproteinintake.
Sedentary
Moderate
20
25
20 10 10
30
Heavy
Pregnant
30
Adult
Woman
women
20 10 10
30
Lactatin9
berulod
greaterbenefit,
althoughthe
possibility
cannot
eakut.Mostpeople,iftheycan,
apparentlychooseto
women
presentthereisnoevidencethat
higher
intakesof
Humanmilk
0-6
months40-60
7-24months35
3-6years
7-9yeaTS
Infants
10 25 25
questionteinthanthe
physiological
requirement.The
beneremainswhetherhighprotein
intakes,farfrombeing
eiclal,mayactuallybeharmful(7)
25
30
35
45
Children
10-12years
13-15years
16-17years
10-12years
13-15years
16-17years
Boys
25 10 15
50
35
aminoa
ids.
The2007WHOExpert
Committee
Report
on
Aminoacidrequirements
proteinintakemustalso
satisfytheneedfor
essential
andProteinuirementsgives
current
estimatesof
hoacid
requirements(in
mg/kgperday)for
adults.
Girls 40
35
Source:(11)
2seare
oducedinTable26.

177. Ithasbeensaidthatfoodisnotonly
nutrientsopentostatisticalordietarysle
simultaneouslyasystemofcommunicationb
customs,situationsandbehaviour.
726
NUTRITIONANDHEALTH
CARBOHYDRATE
Therecommendedintakeofcarbohydrateinbalanced
dietsisplacedsoastocontributebetween50to80percentof
totalenergyintake.MostIndiandietscontainamountsmore
thanthis,providingasmuchas90percentoftotalenergy
intakeinsomecases,whichmakesthedietimbalanced.This
BALANCEDDIET
Adietmaybedefinedasthekindsoffood.
personorgrouplives.Abalanceddiet
isdo
wneedstobecorrectedthroughnutritioneducation.
Therecommendeddietaryallowancesforenergy,
protein,fatandmineralsissummarizedinTable28. antities
z
whichcontainsavarietyoffoodsinsuched
as
forenergy,
aminoacids,ids,vitzni
proportionsthattheneed
minerals,fats,carbohyd andother
adequatelymetformaintaininghealth,vitalitrents
well-beingandalsomakesasmallprovision
durationoflean
OTHERRECOMMENDED INTAKES
Therecommendeddailyallowancesofnutrientsfor
IndiansareassummarizedinTable28;Table29shows
acceptablemacronutrientsdistributionrange;Table30
showssummaryofrecommendedintakeofsomeofthe
mineralsandtraceelements;Table31showsthedaily
nutrientsrecommendationfortheelderlyandTable32
nutrientstowithstandshort
sategad
balanceddiethasbecomeanacceptedmeanstoc
.
populationfromnutritionaldeficiencies(79),
Inconstructingbalanceddiet,thefollowing
prindirp
shouldbeborneinmind:(a)Firstandforemost,
therequirementofproteinshouldbemet.Thisamountsto
10-1
requirement,whichshouldbelimitedto15-30ercent
oithe
showsTolerableUpperLimit(TUL)fornutrients.
percentofthedailyenergyintake.(b)Next
comee
e
Allnutritionalrequirementsareinterrelated.Forexample
thereisacloseinterrelationshipbetweentheenergyand
fordailyenergyintake(c)Carbohydrates
richinnatural
between requirementsrequirements,protein
phosphorus,calciumandvitaminD,betweenfatsand
vitamins,andbetweencarbohydratesandvitamins.
shouldconstitutetheremainingfoodenergy.Thereqsir
bemet
ofmicronutrients(lable28,29,30and31)shouldhe
TABLE28
SummaryofRDAforIndians-2020
FolateVit
B6
Vit
it
Cal-Magn-IronZinclodineThiaRibo-NiacinDietary
Fibre
(g/d)
ProteinCategoryBody
ofwork B12
Age
Group mineflavin
C
Wt ciumesium
(g/d) (mg/d)(mg/d)(mg/d)(mg/d)(ug/day)(mg/d)(mg/d)(mgd)(mg!d)(Hgd)(ug/d)(mgd)(ugdE
kg
1.42.0 14 1.9Sedentary 32
54.0 41 10004401917 150 1.82.5 18 2.43002.2801000600
Men Moderate65
2.33.2 23 3.152Heavy
1.4 1.9 11 1.9Sedentary 25
46.0 32 1000370 29 13 150 1.72.4 14 192202.2 65840600
Moderate55
2.2 3.1 18 2.4
41Heavy
+9.5
(2nd
trimester
+22.0
b5
Pregnant
250 2.02.7+2.52.3570+0.25+15900
6001000440 2714.5Women woman
10
(3rd
trimester)
2.13.0+5+0.26330
Lactation
0-6m
+17.0
280 +1.0+509506001200400 23 14
2.12.9+5+0.17330
7-12m +13.0
30 100 0.204 2 0.12512 20350400
0-6m* 5.8 8.0 300
5 0.68512
30350
400
Infants
300 75 3 2.5130 0.40.66-12m 8.5 10.5
3.3 90 0.7117 0912012
30390
114.5120
0.9
1-3y 12.9 12.5 15 500 90 8
510
600
1.3 9 1.213512 3518.3 16.0 20 550 125Children4-6y
45630
1.6 11 1.51702.223.0 26 650 175 15 5.9120 1.17-9y 25.3
150 1.52.1 15 2.02202.2 55770
600
10-12y34.9 32.0 33 850 240 168.5
600
Boys
790
250 28 8.51501.41.9
14 1.92252.2 50
Girls 10-12y36.4 33.0 31 850
930
600
345 2214.3150 19 2.7 19 2.62852.270
Boys 13-15y50.5 45.0 43 1000
65890
600
16 2.22452.2
340 3012.8150 1.62.2
13-15y49.6 43.0 36 1000Girls
3402.2 85
1000
600
2617.6150 2.2 3.1 22 3.0
50 1050440
Boys 16-18y64.4 55.0
2702.270
860
60
55.7 46.0 38 1050380 3214.2150 1.7 2.3 17 2.3
Girls16-18y
AdequateIntake(Al)
Source:(11)

178. FAT
727
TABLE29 TABLE30
SumAryof
rerernmended
intakesfar
atierhiierals
árnd17ereeiernerits
tsletrat1utriert,tsrititiarTIgetAtADE}
by
Minerals/
genRecommended
intake
TraceElementT.l
Agegroup
S.NoNutrlents
3-1 (perday)
1-2 AdultsPregnantand
lactatingwomenyearsyears
1000mg/day
Phosphorous
Protein(PEralio)"5-15
TotalFat
|n6
PUFA"
n-3PUFA
Carbohydrate
5-15 -15 5-15
20-3530-4025-3515-35
2000mglday
Sodium
4-104-104-10 4-10 3500mg'day
3 Potassium
0.5-10.5-10.5-1 0.5-1
2mg/day
40-6045-6545-65 45-65
4 Copper
4mg/day
Dependsonproleinqualityandfotalenergyintake
#D-6ton-3ratioshouldbebetween5-10:1
ate:Forgoodhealih,adultsshouldconsumeminimumof100to
Manganese
50uo/day
Chromium
Selenium
40ug/day
130go
corlbohydratesandalleast20gfats(foodsources)
Source:(11)
Source:(1)
TABLE31
DailyNutrientrecommendationsfortheelderlyinIndia-2020
NutrlentoHEnergyDietaryProtcinVit-AThiaminRiboflavinNiacinVit-CVit-B,FolateVit-B,,Vit-DCalciumMagnesiumIronZinclodine
B,(mg)(mg)(mg).(mg)(Kcal)ibrej(g(4gB,mg) (4g) (IU)mg (mg) (mg)(mg)(ug)
-
42.9 400 800 370 11 1495
EAR 1700 460 1.6 12 65 1.62502.0
Men
2.28001200 440
1917150
54.0100014F2.0 14
36.33901.1
1.6
260
Y1S
RDA 32 80 1.9300
9551.6 180 2.0400 800 310
111195
Women
EAR
60
Y18
RDA
1500
1913.2150
45.7
840
Thece
lsno
RDAforEnergy.TheEARisequivalentiotheEstimatedEnergyRequirements(EER)
25 1.4 1.9 11 65 1.92002.2800 1200 370
itSource:(11)
TABLE32
TolerableUpperLimit(TUL)forNutrients-2020
ZinclodineNiacinVit.
B
FolateVit.C Vit.AVit.D
Age
Group
Cotegory
ofwork
ProteinCalciumMagnesiumIron
(PEratio)(mg/d) (mg/d) mg/d)(mg/d)4g/day)(mg/d)(mg/d)(ug/d)(mg/d)(Hg/d)(IU/d)
Men Sedentary
Moderale 350 45 40 1100 1000 2000 3000
<40% 2500
auhe
35
Heavy
Sedentary
100 4000
05
Moderate s40% 2500 350ta45
40 1100 1000 2000 3000
Heavy
Pregnant
Women
<30% 2500 350 45 40 1100 1000 2000 30004000
Woman
Lactation
0-6months
7-12months
s40% 2500 350 45 40 1100 1000 2000 30004000
0-6months<15%
40 600 1000
Infants
40 6001500
6-12months<15%
|Chldren
1-3years
200
<15% 1500 65 40 1 350 6002500
110 40 12 300 550 9003000
4-6years
7-9years
<15% 2500
2500 110 40 12 400 300 800 9003000
<15%
600-800
(9-17y)
Boys
10-12years
600 1050
<15% 3000 350 40 23 17004000
600Gids
10-12years
Boys
Girls
<15% 3000 350 40 23 1300 17004000
350 45
34 900 1550 2800400013-15years
13-15yearsS
16-18years
6-18
years
<15% 3000
3000 350 45 34 900 180028004000
s15%
Boys
Glris
3000 350 45 34 1100 195028004000
<15%
350 45341100 200028004000
15%3000
effectse
maximumlevelofhalbitualintakefromallsourcesofanutrientorrelatedsubstancejudgedtobeunlikelytoleadtoadversehealth
Note:1
humans
Valucs
are
onlyfornon-dietarypharmacologicaldoses.
Source:
(11)

179. 750
NUTRITIONANDHEALIH
HealthandFamilyWelfarein1970
On
basj
utrit
deficenoyn
AnaemiaMuktBharatStrategy(175) technology
developedattheNationalInethe
TheAnaemiaMuktBharatStrategyisauniversal
strategy
andwillfocusonthefollowingsixinterventions
1.Prophylacticironandfolicacidsupplementation.
2.Deworming.
atHyderabad.Anevaluationoftheprogramme
ho
revealedasignificantreductiinvitamin
children(seepage705,706fordetails).
2.Prophylaxis
againstnutritionalanaemia
Inviewofitspublichealthimportanco
3.Intensifiedyear-roundbehaviourchangecommunication
campaign(solidbody,smartmind)focussingonfourkey
behaviours(a)improvingcompliancetoironfolicacid
supplementationanddeworming;(b)appropriateinfant
andyoungchildfeedingpractices;
(c)increase
inintake
ofiron-richfoodthroughdiet
diversity/quantity/
frequencyand/orfortifiedfoodswithfocusonharnessing
locallyavailableresources;and(d)ensuringdelayed
cordclampingafterdelivery(by3minutes)inhealth
facilities.
,
anatiOna
angprogrammeforthepreventionofnutritional
launchedbytheGovt.ofIndiaduringthefor
ia
was
thFive
ePlan.Theprogrammeconsistsofdistribution
ofiron
children(1-12ears).MotherandChildHealth
(MCH
folicacid(folifar)tabletstopregnantwomen and
and
young
Centresinurbanareas,primaryhealthcentresin
+
andICDSprojectsareengagedinthe
programme.Thetechnologyforthecontro
inrural
ateasimplement
ofthis
of
throughironfortificationofcommonsalthaenaemia
itiondevelopedattheNationalInstituteofNttbeen
4Testingandtreatmentofanaemia,usingdigitalmethods
andpointofcaretreatment,withspecialfocuson
pregnantwomenandschool-goingadolescents.
ttHyderabad(seepage732formoredetails)
3.Controlofiodinedeficiencydisorders
TheNationalGoitreControlProgrammewaslaunched.
theGovernmentofIndiain1962intheconventional
ce
beltintheHimalayanregionwiththeobjective
identificationofthegoitreendemicareastosupply
10dized
saltinplaceofcommonsaltandtoassessthe
pact
goitrecontrolmeasuresoveraperiodoftimne.
Surveys,however,indicatedthattheproblemof
andiodinedeficiencydisorderswasmorewidespreadthan
wasthoughtearlier,withnearly145millionpeopleestimated
tobelivinginknowngoitreendemicareasofthecountry.
As
aresult,amajornationalprogramme
the
IDDControl
Programme wasmountedin1986withtheobjectivetn
replacetheentireediblesaltbyiodidesalt,ina
phased
mannerby1992(seepage494,733formoredetails).
5.Mandatoryprovisionofironandfolicacidfortifiedfoods
ingovernment-fundedpublichealthprogrammes.
6.Intensityingawareness,screeningandtreatmentofnon-
nutritionalcausesofanaemiainendemicpockets,with
specialtocusonmalaria,haemoglobinopathiesand
fluorosis. of
TheAnaemiaMuktBharatStrategywillbeimplemented
inallvillages,blocks,anddistrictsofallthestates/UTsof
Indiathroughexistingdeliveryplatformsasenvisagedinthe
NationalIronPlusInitiative(NIPI)andWeeklyIronFolic
AcidSupplementation(WIFS)programme(175).
goitre
COMMUNITY NUTRITIONPROGRAMMES
TheGovernmentofIndiahaveinitiatedseverallarge-
Scalesupplementaryfeedingprogrammes,andprogrammes
aimedatovercomingspecificdeficiencydiseasesthrough
variousMinistriestocombatmalnutrition.Theyareas
4.Specialnutritionprogramme
Thisprogrammewasstartedin1970forthenutritional
benefitofchildrenbelow6yearsofage,pregnantand
nursingmothersandisinoperationinurbanslums,tribal
areasandbackwardruralareas.Thesupplementaryfood
suppliesabout300kcaland10-12gramsofproteinper
childperday.Thebeneficiarymothersreceivedaily500kcal
and25gramsofprotein.Thissupplementisprovided
to
themforabout300daysinayear.Thisprogrammewas
originallylaunchedasaCentralprogrammeandwas
transferredtotheStatesectorinthefifthFiveYearPlanas
partoftheMinimumNeedsProgramme(168).Themain
aimoftheSpecialNutritionProgrammeistoimprove
the
nutritionalstatusofthetargetgroups.Thisprogrammei
graduallybeingmergedintotheICDSprogramme.
showninTable38.
TABLE38
NutritionprogrammesinIndia
Programme Ministry
1VitaminAprophylaxis MinistryofHealthand
FamilyWelfare
MinistryofHealthand
FamilyWelfare
MinistryofHealthand
FamilyWelfare
MinistryofSocialWelfare
programme
Prophylaxisagainst
nutritionalanaemia
2
lodinedeficiencydisorders
controlprogramme
Specialnutrition
3.
programme
Balwadinutritionprogramme
6.1CDSprogramme
Mid-daymealprogramme
Mid-daymealscheme
MinistryofSocialWelfare
MinistryofSocialWelfare
MinistryofEducation
MinistryofHuman
ResourcesDevelopment
5.Balwadinutritionprogramme
Thisprogrammewasstartedin1970forthebeneftit
childrenintheagegroup3-6yearsinruralareas.Itisund
theoverallchargeoftheDepartmentofSocialWelfare.
Fo
nationallevelorganizationsincludingtheIndianCounci
ChildWelfarearegivengrantstoimplementthe
program
Voluntaryorganizationswhichreceivethefundsareactv
involvedintheday-to-daymanagement.The
programme
implementedthroughBalwadiswhichalsoprovide
p
primaryeducationtothesechildren.Thefoodsupplem
provides300kcaland10gramsofproteinperchildper
Balwadisarebeingphasedoutbecauseofuniversallzad
ofICDS.
7
8.
1.VitaminAprophylaxisprogramme
OneofthecomponentsoftheNationalProgrammefor
ControlofBlindnessistoadministerasinglemassivedose
ofanoilypreparationofvitaminAcontaining200,000IU
(110mgofretinolpalmitate)orallytoallpre-schoolchildren
inthecommunityevery6monthsthroughperipheralhealth
workers.ThisprogrammewaslaunchedbytheMinistryof

180. ANNEXURES 753
ANNEXURE-2
BALANCED
DIETS
(Thequantitiesaregiveningrams)
Adultman
Children BoysGirlsAdultwoman
SedenModerateHeavy
tary
10-12
Seden
tary
ModeratcHeavy
10-12
dltem
1-3 4-6work
work
years yearswork work years years
460 520 670
410 440 175 270 420 380
reals
575
45
40 50 60
40 45 50 35 35 45
Ises
40 40 40 100
50 40 50 50 50
alyvegetables
100
30 50 50
hervegetables
oofsandtubers
60 70 80 40 100 20
50 60 80 50 50 60 10 20 30 30
150 200 250 100 150 200 300 250 250 250
k
40 45 65 20 25 40 15 25 40 35
ilandFat
30 35 55 20 20 40 30 40 45 45
ugaforJaggery
outcef1358)
ANNEXURE-3
Suggestedsubstitutionfornon-vegetatians
iood
itemwhichcanbedeletediromnon-vegetariandiets Substitutionthatcanbesuggestedfordeleted
itemoritems
S0%ofpulses
(20-30g)
1.
Oneegor30gofmeatorfish
2.Additional5goffatoroil
1.Twae2gsor50gofmeatorlish
2.
Oneeganlua30qmeat10goffatoroil
100%ofpulses
4040
g
Source:(1.38)
ANNEXURE-4
Lowcostlndianvegetarianhighproteindietforanadultwoman
during2ndand3rdirimesterofpregnancy{10kgGWG)
3rdrimester ProteinDigestibleprotein
content"(g/d)
Food
grouP 2ndtrimester
Amount(g'd) contentComposition Amount(g'd)
260 20Cresls&
Milets 325 24
80 1411Pulses
(legumes)
250
Green
lesfy
Vegetables
(GIVs)
Dthervegetables
250
100
99100
30Roots
&tubers 50
50Fruits
50
Milk
andmilk
750 239
300products
22Fats&
oils 30
5ugar
&Jaggery 20
2031tnergy
(kcal} 2019
65Protein
igl 54
13PE
Ratio
1
Valuesndmilletsarepresumedtobeintheratio40:40:20forrice:wneat:mile1s(HaguBajra/Jowar).Forcalculation
purposo
nd
athreemilletsareaveraged.Spinach,frenchbeans,potaoangua
pesenS gTeeniealyvegetables,othervegetablesro
bRe
druitsrespectively.Sourceofnutritivevaluesoffoods:IFCT,2017,
Crecn
digestible
proteincontent
ofthediet.Protein
contentsofeachfoodgroup(exceptforGLVs,rootsandtubers.fruits).are
Cedforiruefaecaldigestibilüiyvalues
Sourte:
(11)

181. 754
NUTRITIONANDHEALTH
andserumtriglycerides.Thisalsob
ANNEXURE-5
cholesterolinblood.Simplemodificaates
in
H
ifeste
ead
ofu3ine
Exerciseandphysicalactivity deliberatelyclimbingupthestairs
inst
of
and
walkingforshortdistanceinstead
Individualsovertheageof20yearsshouldundertakea
minimumof30minutesofphysicalactivityofmoderate
intensity(suchaswalking5-6km/hr)onmost,ifnotall
daysoftheweek.Greaterhealthbenefitscanbeobtained
byengaginginphysicalactivityoflongerdurationormore
vigorousintensity(suchasjogging,running,cyclingand
swimming)
couldalsoimmenselyhelpinincreadiingreasing
ouractivity.
Exerciseprogrammeshouldinclude
down'periodseachlastingfor5minut
up
theintensityofexerciseshouldensure60.ng
e
heartrate
wa
Caerea
and
Sedentarypeopleembarkingonaphysicalactivity
programmeshouldundertakeamoderateintensityactivity
ofshortdurationtostartwithandgraduallyincreasethe
durationorintensity.Otherday-to-dayactivitieslike
walking,housework,gardening,willbebeneficialnotonly
nweightreductionbutalsoforloweringofbloodpressure
Previouslyinactivemenovertheage
of
40womenovertheageof50yearsandpeo
chronicdiseaseslikeheartdisease
athigh
firstconsultaphysicianbeforeengaginainetes
progam
sh
ofvigorousphysicalactivitysuchas
running
swimming.
Computationofenergyexpenditureofadult
Indianpopulationusingfactorialapproach
Majorlifestyles,energyexpenditure
(PARvalues)
Maindailyactivities Duration(h)
ModerateSedentary
Heavy
or
vigorousty
active
active
Sleep
1.0 1.0
8
1.0
1.3 2.5
Occupationalactivity 8
4.1
Non-occupationalactivity 8 1.9 1.9
19
Mean 1.41 1.80
2.33
Non-occupationalactivity
Personalcare 1.6 1.6 1.6
Eating 1.2 1.2 1.2
2.0 2.0Commutingtoworkbybusor
byvehicleorbywalk
1 2.0
Generalhouseholdorother 2 2.0 2.0 2.0
activities
3.4Walkingatvariousspeeds
withoutload
1 3.4 3.4
Lightleisureactivity 2 1.4 1.4 14
Meannon-occupationalactivity 8 1.9 1.9 19
Menbodywt.(65kg),
BMR(1506kcal) 2123 2711
3509
1670 2131
2759
Women:bodywt.(55kg),
BMR(1184kcal)
Source:(11)

182. 888
HSPEA.
WARIE
MANACEMINT
Part2
disposal
facilityof
TSDFsorplasr
1200"C
asma
p
plast
bays
shallbe
as
per
1315
standards
asand
when
Pbshed,il
thenthe
prevailing
plastie
waste
1anagement
rules
shallbe
appicalle.
hemieal
Tyeatment
using
at
least
10%
Sodium
typochlorite
having
30%
1esidual
chlorine
for
twenty
miutes
orany
other
equivalent
chemlcal
reagentthat
should
demønstrate
Log,,4
reduction
efflciencyfor
microp
vganisvs
Mutilationor
shredding
mustbe
toon
extent
to
prevent
nauthorited
reuse
here
willbeno
chemical
pretreatmentbefore
incineration,
except
tor
mierobiological,laband
highly
infectious
waste
cineration
ash
(ash
from
incineratlonof
any
bio-medical
waste)
shall
be
disposed
through
hazardous
waste
treatment,
storageand
disposal
facility,Iftoxlcor
hazardous
constittents
are
present
beyond
the
prescribed
limitsas
9ven
inthe
Hazardous
Waste
(management,
handlingand
transboundary
movement)
Rules,
2008,oras
revised
from
timeto
time,
R
Residualordiscarded
chemical
wast
infectantsand
Chemicalsludgeed
hazardous
waste
treatment,storad
suchca5e,theaste
shouldbe
reatment,slorageand
disposalfar
tohaa
common
bio-medical
waste
treatmentugh
only
9.
On-sjte
pre-treatmentof
laborator
waste,blood
samples,bloo
sterilizedasperthe
guidelinesofWorld
Health
disn
Gr
terilizedsIOSControlOrganisationandth
geand
and
duposa
rywaste
micr
oodbags
National
bio-medicalwastetreatment
an
facility,
10.
Installationofin-house
incineratorisalloe
omedicalfacilft
wed.
Howen
same
maybe
installedbythe
ty
noser
authorizationfromtheState
PollutionContafter
casethere
1sno
commonbiom
he
Unite
UNISDR)
(2
the
functio
widespread
11,
Syringesshouldbe
either
mutilatedorne
andorstoredin
tamperproof,leak
ard
Dead
foetus
belowthe
viability
period
(asperthe
Medical
Terminationof
Pregnancy
Act
1971,
amended
from
timeto
tme
canbe
consideredas
human
anatomical
waste,Such
waste
shouldbe
handed
overtothe
operatorof
common
bio-
medical
waste
treatmentand
disposal
facilityin
yellow
bag
witha
copyofthe
official
medical
terminationof
pregnancy
certificate
romthe
obstetricianorthe
medical
esshould
e
proof
containersfor
sharp
storage.
Wherevorpun
notlinkedtoadisposal
facilityitshallbe
ihOCCupp
ofthe
Occupier
tosteril1zeand
disposeintb
akproof
communit
UNISDR
prescribed.
osses
and
nanne
12.
Bio-medical
wastegeneratedin
householde
healthcare
activitiesshall
Desegregatedasper
thes
and
handed
overin
separatebagsor
contain
municipal
waste
collectors.
Urban
Local
Bodioe
tieupwiththe
commonbio-medicalwaste
treatme
disposal
facilitytopickup
this
wastefromthe
Ma
Recovery
Facility
(MRF)oTfromthehouseholddirect
finaldisposalinthe
mannerasprescribedinthis
schedule
ot
many
ditio
superintendentof
hospitalor
healthcare
establishment
(7)
Cytotoxic
drug
vials
shallnot
be
handed
overto
unauthorized
personunder
any
circumstances.
These
shall
besent
backtothe
manufacturersfor
necessary
disposalat
asingle
point.
Asa
second
option,
these
maybe
sentfor
incinerationat
common
bio-medical
waste
treatmentand
capacity
negafiv
inife,
physie
to
pra
econ
The
bio-medical
waste
shouldbe
segregated
into
containers/bagsatthepointof
generationofthe
waste
colour
codingandthetypeof
containersusedfor
disposalof
wasteareas
shown
inFig.2
showsthe
labelfor
bio-hazards
symboland
cytotoxic
hazard
symbol
which
shouldbe
prominently
visibleand
non-washable.
COVID-19hashadaserious
impactonallaspectsofg
society,and
waste
managementisno
exception.
Thereh
beenan
increased
amountof
potentially
infectedwaste
whichrequires
additional,
careful
handlingand
treatment
processesto
sateguardthe
wastehandlersand
sanitation
workers
associated
withsuch
healthcare
facilities.Fot
operatedlidsin
colour-codedbins
mustbe
introducedto
avoid
contact
contaminatedby
patient's
secretionsand
body
fluids.
Wet
anddry
solidwastebags
mustbetied
securely.Althe
wasta
handlers
must
followthe
preventive
measures
like
hand
washing,using
glovesand
mask,and
other
personal
protective
equipments.
the
O
nave
Bio-hazard
Symbol
Cytotoxic
Hazard
Symbol
Generalsolid
waste
shouldnot
be
References
1.
Sharma,
A.K.(1998).
Bio-Medical
Waste
(Management
Handling)
Rules,1998,
SuvidhaLaw
House,
Bhopal
Pruss,A.,
Cirouit,E.,and
Rushbrook,P
(1999
2
Managementof
Wastesfrom
Health-Care
Activities,
1999
Bio-hazard
Cytotoxic
HANDLEWITHCARE
Rao,
H.V.N.(1995).
Disposalof
Hospital
Wastesin
Bangalo
FIG.2
heir
Impacton
Environment,
Appropriate
Waste
Mand
lechnologiesfor
Developing
Countries,
3rdInte
ScheduleI
Labelfor
bio-medicalwaste
containers/bags
Note:Labelshallbe
non-washableand
prominently
visible,
Conference25-26Feb1995,
Nagpur,
Technical
Papers
4
Govt.ofIndia(2016).
Ministryof
Environment,r
Climate
Change,
Notification
publishedinthe
Ga2ete
Bio-Medical
Waste
Management
Rule2016.

183. 933
ALCO
TOLISMANDDRUG
DEPENDENCE
TABLE2
oncocaine,ATSandHallucinogens
isextremelysmal
Incomparisontothesizeofcountry'spopulation.aclors
associatwilliahighrisklordrugabuse
.
Nationally,itisestimatedthatthereareabout8.5lakh
peoplewhoinjectdrugs(PWID).Opioidgroupofdrugs
arepredominantlyinjectedbyPWID(heroin
-
46
per
centandpharmaceuticalopioids
-46percent).A
substantialproportionof
injectingpractices.
areestimatedinUttarPradesh,Punjab,Delhi,Andhra
Pradesh,Telangana,Haryana,Karnataka,Maharashtra,
ManipurandNagaland.
certainoccupations
(lourism,drugproductionorsale)
areaswithhighratesofcrime
unemployment
living
awayfrom
home
migrationtocities
relaxed
parentalcontrol
alienationfrom
family
early
exposuretodrugs
leavingsch0olearly
brokenhomes;
one
parent
families
largeurban
environments
areaswheredrugsaresold,
raded,or
produced
orvice
PWID
numbers
report
of
risky
PWIDareaswheretherearedrug-
usinggangs
High
-areaswheredelinquencyis
commOn
Prevention
Approachestopreventionofdrugdependenceshould
haverealisticaims.Over-ambitioushopesoferadicatinga
drugprobleminashorttimearelikelytoleadtopolici1es
thatareunrealisticandself-discrediting.Changesinculture
attifudesandalterationinrelevantaspectsofthe
environmentcanbebroughtaboutonlyslowly.
Source:/8)
MagnitudeofsubstanceabuseinIndia(18)
ANationalSurveywasconductedbetweenDecember
9017
andOctober2018.Theprimaryobjectiveofthe
surveywastoassesstheextentandpatternofsubstanceuse
ineachstate/UT.Thekeyfindingsoftheuseofpsychoactive
Legalapproach:Thelegalcontrolonthedistributionof
drugs,wheneffectivelyappliedhasbeenandremainsan
importantapproachinthepreventionofdrugabuse.Controls
maybedesignedtoimposepartialrestrictionortomakea
drugcompletelyunavailable.Legislationmaybedirectedat
controllingthemanufacture,distribution,prescription,price
timeofsale,orconsumptionofasubstance.
SubstancesinIndiaisasfollows(18).
Alcoholisthe
1.Alcohol
DsychoactivesubstanceusedbyIndians.Nationally,
about14.6percentofthepopulationbetween10and
75yearsofage
absolutenumbers,about16crorepersonsconsume
alcoholinIndia.Itisconsiderablyhigherinmen(27.3
percent)thanwomen(1.6percent).Amongalcohol
users,countryliquorordesisharab(about30percent)
andspiritorIndianmadeforeignliquor(about30per
cent)arepredominantlyconsumedbeverages.Ofthe
14.6percent(16crore)users,5.7crore(5.2percent)
areproblemusersand2.9crore(2.7percent)are
dependentusers.
mostcommon
Legislationrestrictingorprohibitingadvertisementsthat
directlyorindirectlypromoteuseoftobaccoandalcoholhas
beenincreasinglycommoninrecentyears.Theantismoking
measuressuggestedare
:(a)prohibitionofthesaleof
tobaccoproductstominors;(b)restrictiononthesaleof
cigarettesfromautomaticvendingmachines;(c)prohibition
ofsmokinginschoolsandotherplacesfrequentedbyyoung
people;(d)prohibitionofsmokinginpublic;(e)prohibition
ofcigaretteadvertisingattimes,andinplacesandways,
calculatedtoensureitsmaximumimpactonadolescents;
(f)establishmentofmandatorypublichealtheducationon
healthconsequencesofsmoking:(g)insistingontheplacing
ofmandatoryhealthwarningoncigarettepackets.
Theminimumageatwhichminorsmaylegallyhave
accesstoalcoholicbeverages,hasbeenraisedinsome
countries.Thereisalsolegislationcontrollingthe
distributionofalcoholinsomecountries.Mandatoryjail
sentencesfordrunkendrivinghavenotbeenveryeffective.
alcohol.Intermsofuses
2.Cannabis Cannabis
used
arethenextcommonly
bstance.About2.8percentofthepopulation
(3.1croreindividuals)reporthavingusedany
cannabisproductwithinthepreviousyear.Thelegal
orm(bhang)wasusedby2.2crore(2percent)and
1.3
crore
(1.2percent)personsusedillegalform(ganja
andcharas).Outof3.1crorecannabisusers,about
72lakhsareproblemusersand25lakhsaredependent
users.Thehighest
useofcannabiswasrecordedinUttar
Pradesh,Punjab,Sikkim,ChhattisgarhandDelhi.
3.
Opioid:About2.1percent(2.3crore)populationin
ndiauseopioidswhichincludesopiumoritsvaríants
Kepoppyhuskknownasdoda/phukki,heroinorits
impureformsmackorbrownsugarandavariety
9pnarmaceuticalopioids.Outof2.3croreusers,about
aareproblemusers(opium11lakhs,heroin63
S
andpharmaopioid25lakhs),and28lakhsare
Educationalapproach:Educationalapproachestothe
preventionofdruguseanddrug-relatedproblemshavebeen
usedinmanycountries.
includededucationalprogrammesforschoolchildrenand
publicinformationcampaignsonelectronicmedia.General
principlesofcommunicationcanbeappliedtoincreasethe
effectivenessofeducationalapproach.Themessageshould
clear
Commonapproacheshave
ndunambiguoustotheintendedaudience,andbe
comefromcrediblesourceofintormation.Themessage
shouldalsoprovidespecificadvice,ratherthangeneral,and
asfaraspossibletheinformationshouldbenewtoth
audienceandshouldbecapableofprovokingdiscussiono=
action.Educationalapproachshouldnotbeplannedan
carriedoutasisolatedactivity.Tobeeffective,sucF
approachesshouldberegardedasapartofintegratedplar
ofactioninvolvingotherstrategies
Communityapproach:Thenon-medicaluseofthedrug
individuallyaswellasinitsmassappearanceinvolves
complexinteractionotdrug,man,andhisenvironmen
includingsocial,economic,cultural,politicalandothe
dependent
users.
S1zeablenumberofpeopleuseotherdrugslike
vesandinhalants.Inthegeneralpopulation,
o .2percentofIndiansneedhelpfortheir
estiuseproblems.Atthenationallevel,an
hol.ted4.6lakhschildrenand18lakhsadultsneed
eD
for
theirinhalantuse(harmfuluse/dependence
ntermsofabsolutenumbers,stateswith
tePopulationofchildrenneedinghelpforinhalant
use
are:UttarPradesh,MadhyaPradesh,
Maharashtra,
Delhi
andHaryana.Thenumberofpeopledependent

184. 970
HEALTHFLANNG
ANDMAAGEMET
establishregistriesfordiseasesofpublichealth
importanceby2020.
Establishfederatedintegratedhealthinformation
architecture.healthinformationexchangesand
nationalheaithinformationnetwor
1he
strong
1
arOgnized
non-
(1)Watersupplyandsanitation;
(2)Controlofcommunicablediseases;
(3)Medicaleducation,trainingand
research:
(4)Medicalcare
including
hospitals,
dispensari.
2025.
HEALTHPLANNINGININDIA
primaryhealthcentres:
(5)Publichealthservices;
CVen
ar
aries
nfth
servic
ut
Civen/
s/orm
p
ntry
aS
HealthplanninginIndiaisanintegralpartofnational
socio-economicplanning(2,13).Theguide-linesfor
nationalhealthplanningwereprovidedbyanumberof
commieesdatingbacktotheBhorecommitteein1946.
ThesecommitteeswereappointedbytheGovernmentof
Indiafromtimetotimetoreviewtheexistinghealth
situationandrecommendmeasuresforfurtheraction.
and
(6)Familyplanning:and
(7)Indigenoussystemsofmedicine.
Alltheabove
considerationintheFiveYearPlans.However,theeuehaschangedfromPlantoPlandepending
nasisfelt-needsofthepeopleandtechnicalconsiderathe
giveeffecttoabettercoordinationbetweentheCentr10
StateGovernments,aBureauotPlanningwasconstitutoa
1965intheMinistryofHealth,Govt.ofIndia.ThonfunctionofthisBureau
iscompilationofNafio
HealthFiveYearPlans.TheHealthPlanisimplement
atvariouslevels,e.g.,Centre,State,District,BlockVillage.
lear
P
Oneol
sub-sectors
have
received
d
d
alforda
TheAlma-AtaDeclarationonprimaryhealthcareandthe
NationalHealthPolicyoftheGovernmentgaveanew
directiontohealthplanninginIndia.makingprimaryhealth
HSTem
neans
n<
rdabl
dined
atloraal
carethecentralfunctionandmainfocusofitsnational
healthsystem.ThegoalofnationalhealthplanninginIndia
wastoattainHealthforAllbytheyear2000.
HLEG)
Ensuri
pETcenta
PLANNINGCOMMISSION
ented
and
of
the
TheGovernmentofIndiasetupaPlanningCommission
in1950tomakeanassessmentofthematerial,capitaland
humanresourcesofthecountry,andtodraftdevelopmental
plansforthemosteffectiveutilizationoftheseresources.In
1957.thePlanningCommissionwasprovidedwitha
PerspectivePlanningDivisionwhichmakesprojectionsinto
thefutureoveraperiodof20to25years.ThePlanning
CommissionconsistsofaChairman,DeputyChairmanand
5members.ThePlanningCommissionworksthrough
3majordivisionsProgrammeAdvisers.General
SecretariatandTechnicalDivisionswhichareresponsiblefor
scrutinizingandanalyzingvariousschemesandprojectsto
beincorporatedintheFiveYearPlans.Overtheyears,the
PlanningCommissionhasbeenformulatingsuccessiveFive
YearPlans.Byitstermsofreference.thePlanning
Commissionalsoreviewsfromtimetotimetheprogress
madeinvariousdirectionsandtomakerecommendationsto
Jender
FIVEYEARPLANS(26,27,28)
4ppros
preves
Thefiveyearplanswereconceivedtore-build
ruralIndiatolaythefoundationsofindustrialprogressandtosecurethe
balanceddevelopmentofallpartsotthecountru.Recognising"health"asanimportantcontributoryfactorin
theutilisationofmanpower
andtheuplittingofthe
economicconditionofthecountry,thePlanningCommission
gaveconsiderableimportancetohealthprogrammesinthefive
yearplans.Thebroadobjectivesofthehealthprogrammes
duringthefiveyearplanshavebeen
indi
(1)Controloreradicationofmajorcommunicablediseases;
(2)Strengtheningofthebasichealthservicesthroughthe
establishmentofprimaryhealthcentresandsubcentres
(3)populationcontrol;and
Governmentonproblemsandpoliciesrelevanttothe
pursuitofrapidandbalancedeconomicdevelopment.The
planningprocesswasdecentralisedtowardsDecentralised
DistrictPlanningbytheyear2000.
(4)developmentofhealthmanpowerresources
TwelfthFiveYearPlan(2012-2017)
Thehealthofanationisanessentialcomponentof
development,vitaltothenation'seconomicgrowthand
internalstability.Assuringaminimallevelofhealthcareto
thepopulationisacriticalconstitutentofthedevelopment
NITIAAYOG
GovernmentofIndiahasestablishedNITIAayog
(NationalInstitutionforTransformingIndia)toreplace
PlanningCommissionon1stJanuary2015.
Itwillseekto
provideacriticaldirectionalandstrategicinputintothe
developmentprocess.NITIAayogwillemergeasa"think-
tank"thatwillprovideGovernmentsatthecentralandstate
levelswithrelevantstrategicandtechnicaladviceacrossthe
spectrumofkeyelementsofpolicy.Inaddition,theNITI
Aayogwillmonitorandevaluatetheimplementationof
programmes,andfocusontechnologyupgradationand
capacitybuilding.
process.
Sinceindependence,Indiahasbuiltupavasthealth
infrastructureandhealthpersonnelatprimary,secondary
andtertiarycare
inpublic,voluntary,andprivatesectors.
Forproducingskilledhumanresources,anumberofmedical
andparamedicalinstitutionsincludingAyurveda,Yogaand
Naturopathy,Unani,SiddhaandHomeopathy
(AYUSH
institutionshavebeensetup.
Considerableachievementshavebeenmadeoverthelast
sixdecadesintheeffortstoimprovehealthstandards,such
aslifeexpectancy,childmortality,infantmortality,
arn
maternalmortality.Smallpox,guineaworm,poliomyeu
havebeeneradicated.Nevertheless,problemsabou
Malnutritionaffectsalargeproportion
ofchildren.
unacceptablyhighproportionofthepopulationcontinues
sufferanddiefromnewdiseasesthatareemerging,
apc
fromcontinuingandnewthreatsposedbytheexisting
ons
Pregnancyandchildbirthrelatedcomplicationsa
contributetothesufferingandmortality.:
HEALTHSECTORPLANNING
Since"health"isanimportantcontributoryfactorinthe
utilizationofmanpower,thePlanningCommissiongave
considerableimportancetohealthprogrammesintheFive
YearPlans.Forpurposesofplanning,thehealthsectorhas
beendividedintothefollowingsub-sectors(25).

185. 972
LALIPLANNINGANIDMANAGEMENT
HEALTH
SYSTEM
ININDIA
TABLE4
IndiaisaUnionof29Statesand7Union
theConsitutionofIndia,theStates
aro
erritories
Achievementsduringtheplanperiocds
1stPlan
1951-5
3yearsaction
agenda2019 inmattersrelatingtothedeliveryof
hcare
to
inden
thepeor
ependenn
EachState,therefore,hasdeveloped
its
own
system
ofhea
1.PrimaryHealthCentres
2.Subcentres
3Community
healthcentres
4.
24,855
157,411
5,335
713,986
529
725
caredelivery,independentoftheCentralGo
healthNA
The
Centralresponsibilityconsistsmainly
ofnmen
policy
makn
planning,guiding,assisting,evaluating,
and
co
Ministries,
sothat
hea
Ordinating
he
Totalbeds(2017)
5.Medicalcolleges
6.
125,000
42
workoftheStateHealth
tvces
covereverypartotthecountry,andnoStato
1 Servie
lags
Annualadmissions
inmedicalcolleges
7.Dentalcolleges
8.Allopathicdoctors
9.
Nurses(registered)
10.ANMs(registered
11.Healthvisitors
12.HealthWorkers(F)
(inposition)
13.HealthWorkers(M)
(inposition)
14.BlockExtensionEducator
15.HealthAssistant(M)
(inposition)
16.HealthAssistant(F}/LHV
(inposition)
17.FirstReferralUnits
58,756
eind
lor
system
inIndia
has
3main
3,500
wantoftheseservices,Theheal
313 links,i.e.,Central,StateandLocalorperipheral
7
65,000
18,500
12,780
578
1,154,686
1,980,526
860,927
55,675
234,220
I-ATTHECENTRE
Theofficial"organs"ofthehealthsystem
atthe
na
levelconsistof
:(1)TheMinistryofHealthantional
Welfare;(2)TheDirectorateGeneralofHealthSetedmuly
(3)TheCentralCouncilofHealth
andFamilyWelfare
1.UnionMinistryofHealthandFamilyWelfar
59,348
3,512
13,446
(1)ORGANIZATION
TheUnionMinistryofHealthandFamilyWelfare
isheaded
byaCabinetMinister,aMinisterofStateandaDeputyHealth
Minister.Thesearepoliticalappointments.Currently,
the
UnionHealthMinistryhasthefollowingdepartmenis
(1)DepartmentofHealthand(2)DepartmentofFamily
Welfare.TheHealthDepartmentisheadedbyaSecretary
to
theGovernmentofIndiaasitsexecutivehead,assistedby
jointsecretaries,deputysecretariesandalargeadministrative
staff.TheDepartmentofFamilyWelfarewascreatedin1966
withintheMinistryofHealthandFamilyWelfare.The
SecretarytotheGovt.ofIndiaintheMinistryofHealthand
FamilyWelfareisinoverallchargeoftheDepartmentof
FamilyWelfare.HeisassistedbyanAdditionalSecretary&
Commissioner(FamilyWelfare),andoneJointSecretary
13,786
3,204
Source:(31)
Theinvestmentsduringdifferentplanperiodsislistedon
page600.
ThreeYearActionAgendaofNitiAayog
(2017-18to2019-2020)
On1stJanuary2015,TheNationalInstitutionfor
TransformingIndia(NITIAayog)cameintoexistenceasthe
Government'spremierthinktank.Itwastoldtopreparea
15yearvision,SevenYearStrategyandThreeYearAction
Agendadocuments.Accordingly,theVisionStrategyand
ActionAgendaisadeparturefromtheFiveYearPlan
process.The12thFiveYearPlanwasthelastoftheseplans.
TheThreeYearActionAgendaoffersambitiousproposals
forpolicychangeswithinarelativelyshortperiod.The
proposedAgendaiswide-rangingandthespecifichealth
goalstobeachievedbytheyear2020areasfollows(30):
1.Reducematernalmortalityratioto120/100,000live
births(2013estimate:167/100,000livebirths).
2.Reduceinfantmortalityrateto30/1,000livebirths
(2013estimate:40/1,000livebirths).
Reduceunder5mortalityrateto38/1,000livebirths
(2015estimate:48/1,000livebirths).
4.ReduceTotalFertilityRateto2.1(2013estimate:2.3).
5.ReduceincidenceofTBto130/100,000(2015estimate:
217/100,000).
6.Reduceincidenceofmalaria(annualparasiteincidence)
tolessthan1/1,000in90%ofdistricts(2016estimate:
74%ofdistrictshaveachievedanAPIoflessthan1).
7,EliminateKala-azar(2015estimate:80%ofendemic
blockshaveeliminated)andLymphaticFilariasis(2015
estimate:87%ofendemicdistrictshaveeliminated).
8.Reduceprematuremortalityfromcardiovascular
diseases,cancer,diabetesorchronicrespiratorydiseases
by
1/4thofNationalFamilyHealthSurvey-4(NFHS-4)
levels.
9.Reduceout-of-pocketspendingto50%ofthetotal
healthexpenditure(2014estimate:62.4%).
(2)FUNCTIONS
ThefunctionsoftheUnionHealthMinistryaresetoutin
theseventhscheduleofArticle246ofthe
Constitution
o
Indiaunder(a)theUnionlistand(b)theConcurrentlst.
(a)Unionlist:ThefunctionsgivenintheUnionlist
are
(Internationalhealthrelationsandadministraioh
quarantine(2)Administrationofcentralinstitutes
sucn
AllIndiaInstituteofHygieneandPublic
Health.
ola
NationalCentreforDiseaseControl,Delhi,etc.
(31Promat
research
throughresearchcentres
andotherDou
4)Regulationanddevelopmentofmedical,pharmatend
aentalandnursingprofessions(5)Establishmend
maintenanceofdrugstandards(6)Census,andcoleanand
publicationofotherstatisticaldata
(7)Immiramines
emigration(8)Regulationoflabourin
andoilfieldsand
(9)
CoordinationwithStatesandwlu
h
other
ministriesforpromotionofhealth.
the
working
of
n
b)Concurrentlist:Thefunctionslisteation
and
Concurrentlistaretheresponsibilitof
boththe
Unio
Stategovernments.TheCentreandthe
simultaneouspowersoflegislation;the
powersofthe
later
rare
States
have
restrictedtotheframeworkofsuchlegislatio.includes
undertakenbytheCentre.The
)Preventionofextensionofcommunicaoe
oneunittoanother(2)Prevention
diseases
from
(5)
Labour
and
social
(3)Controlofdrugsandpoisons(4)Vital
statistics
welfare(6)Portsotherthannajor
(7)Econo
planning,and(8)Populationcontrolandran
ily
Planning

186. HISTORYOFPUBIIC
HEALTHININDIA979
InfantandYoungChildFeedingformulatedin 9.WHO(1973).ApplicationofModernManagemente
buidelin
.2004.
ethodsand
nues
jortheimproveddeliveryofHealthSeruices,SEA/PiA
o005:(1)RCH
IIlaunched(2)JananiSurakshaYojana
120,WHO,NewDelhi.
(3)NationalRuralHealthMissionlaunched
launched
Indian
PubliciealtnstandardsforCommunityhealth
I0.Srivastava,
A.B.L.etal(1974).
NIHAEBulletin,7,29-55.
1.Sharma,H.R.(1969).NIHAEBulletin,
2No.1,pp.29-39.
12.Govt.ofIndia(2017).NationalHealthPolicy-2017,Department
or
Health,MinistryofHealthandFamilyWeltare,NewDeini
13.Rao,S.K.(1969).NIHAEBulletin,2.No.3,pp.5-19.
4.Govt.
ofIndia(1946).Reportofthe
HealthSurveyand
Development
Committee,Govt.ofIndiaPress,Simla.
formulated(5)Indiaachievedleprosyelimination
centres
arge
TGet
byendotz005(6)NationalPlanofActionfor
Children2005
tormulated.
2006
(1)WHOreleases
newpaediatricgrowthchart
hasedonbreast-fedchildren(2)Banonchildlabouras
domesticservant(3)RNICPcOverswholecountrysince
15.Govt.
ofIndia(1962).ReportoftheHealthSurveyandPlanning
Committee,MinistryofHealth,NewDelhi.
March2006(4)NationalFamilyHealth
Survey-3conducted
61MinistryofWomenandChildDevelopmentcarvedout
b.Chadha,M.S.(1963).ReportoftheSpecial
Committee
ontne
DreparationforentryoftheNMEPintotheMaintenancePhase,
MinistryotHealth,Govt.ofIndia.
17.Mukherjee,
B.(1966).Reporton
ReorganizationofFamityPianning
oftheMinistryofuman
KesourcesandDevelopment
(6)
IMNCIwaslaunchedin16states.
2007(1)11thFiveYearPlanlaunched(2)NACPIII
launched(3)IndianPublicHealth
StandardsforPHCand
sub-centrestormulated
(4)Maintenanceand
welrare
or
19.
Govt.ofIndia(1973).ReportoftheCommittee
onMulipurpose
ParentsandSeniorCitizens
Bill2007passed.
eruices,
AdministrationandBasicHealthServices.Ministryot
Health.Govt.ofIndia.
18.Govt.ofIndia(1967).ReportoftheCommitteeonIntegrationof
HealthSeruices,
DirectorateGeneralofHealthServices,Ministryof
1ealth,
NewDelhi.
Workersunder
Healthand
FamilyPlanning
Programme,Deparnent
ofamily
Planning,
MinistryofHealthandFamiyPlanning.New
Delhi.
2008(1)
Non-communicableDisease
Programmeas
pilotprojectlaunchedon4thJan.
2009Pandemic
InfluenzaA(H,N,)2009outbreak,
NewICDSMotherandChildProtectionCardcameintouse.
20.Govt.ofIndia(1975).MinistryofHealthand
FamilyPlanning(1975).
KeportoGrouponMedicalEducationandSupport
Manpower,New
Delhi.
2010lCMR
announcesnutrients
requirementsand
recommendeddietaryallowancesforIndians.
21.Govt.ofIndia(1976).SwasthHind,20,233.
22.SharadKumar(1976).NIHAEBulletin,IX,105-109.
23.Govt.ofIndia(1981).Reportofthe
WorkingGrouponHealthforAll
by2000
AD,MinistryofHealthandramilyWeltare.
2011
:Indiastagessecondcensusofthe
century.
2013National
HealthMissionlaunched,
RMNCH+A
Strategylaunched.
24.ICSSRand
ICMR(1980).HealthforAll
-AnAlternativeStrategy,
IndianInstituteofEducation,Fune.
25.
Shrivastav,J.B.(1972).IndianJ.Med.Edu.,XI,99.
26.Dhir,S.L.etal(1972).NIHAEBulietin,5,179-186.
2014
(1)IndiaNewbornActionPlanlaunched
on
2/thMarch.(2)Indiadeclaredpoliofree
country.
3)MissionIndradhanushlaunchedon25th
December.
27.Govt.ofIndia,
Planning
Commission(1974).DraftFijfthFiveYear
Plan,1974-19,
vOI.l&
l1,ControllerotPublications,Delhi.
28.Govt.ofIndia(1987).India
AReference
Annual,1986Director,
PublicationsDivision,MinistryofIntormationandBroadcasting.
2015:
(1)NITIAayogreplaces
YojanaAayogonist
danuary2015;(2)UseofIPVin
immunizationschedule
IromNov.2015;(3)Juvenile
JusticeAct2015;and
14)SwachhBharatAbhiyanlaunched.
29.Govt.ofIndia(2014),TwelfthFiveYearplan(2012-2017),Social
Sector,vol.ll,Planningcommission,Govt.oflndia.
30.NitiAayog2017)hree
YearActionAgenda2017-18to
2019-2020,Govt.ofIndia,NewDelhi.
31.Govt.ofIndia(2019).BulletinonRuralHealthStatisticsinIndia,
2018-19,
InfrastructureDivision,MinistryofHealthandFamily
Velfare,NewDelhi.
2016:
(1)Sustainable
Development
Goals
officially
ameintoforceon1stJan.2016;(2)
Anganwadi
workers
now
government
employees;
(3)Malaria
eradication
Pan
(2016-2030)
launched;and
(4)SwitchfromtOPVto
bOPVinApril2016.
32.Govt.
ofIndia,(1964).
PanchayatiRaj,MinistryofCommunity
Development,NewDelhi.
33.Govt.ofMadhya
Pradesh,Bhopal(1962).Guide
Notes,Trainingof
OfficialsandNon-officialsinPanchayatiKaj,Govt.CentralPress,
Bhopal.
34.BarkatNarain(1961).SwasthHind,Souvenir,
Feb.1961,p.189.
35.
Deniston,
O.L.etal(1968).PublicHealthReports,83:323.
36.
Tanahasi,
T.(1978).BullWHO,56:295.
37.Dept.
ofHealthandSocialSecurity,ScottishOffice(1969).The
FluoridationStudiesinthe
UKandresultsachieuvedafter1lyears.
ReportonPubliciealthandMedicalSubjectsNo.22,HMSO,
017
:(1)
Aadharnumber
mustfordeath
certificate
romOct.2017;(2)NationalHealthPolicy2017.
2018
(1)
National
Health
Protection
Scheme;
12)AyushmanBharatlaunched.
019
RNTCP
renamed
National
Tuberculosis
CiminationProgramme(NIE
2020
(1)New
commission
replacesMCINational
edical
Commission"on25.9.20;
(2)
COVID-19Pandemic
playedhavocintheworld.
London.
38.Sanazaro,PJ.(1974).Brit.Med.J.,1:271.
39.WHO(1981).HealthforAllSr.No.6,WHOGeneva.
40.Abramson,J.H.(1979).SurveyMethodsinCommunityMedicine.
2nded.ChurchillLivingstone.
41.WH0,
SEARO(1984).HealthPlanningand
ManagementGlossary
SEAROReg.HealthPapersNo.2,NewDelhi.
42.Alderson,
M.R.andRobinD.(1979).HealthSurveysandRelate-
:3
Referencesi.
1974).Modern
ManagementMethodsandthe
Organizationoj
Health
Services,PublicHealthpaperS
Studies,PergamonFress.
Pan
APproachesto
NationalHealth
Planning,
PublicHealth
43.Cochrane,
A.L.(1972).
Effectivenessand
Efficiency,Nuffiel
ProvincialHospitalTrust,London.
44.
Deniston,
O.L.etal(1968).PublicHeaithReports,83:603.
45.WHO(1971).Techn.Rep.Ser.,No.472.
46.
..971).
Planning,and
Programmingforursingerice
ubiicHealthPapers44
E
narma,H.R.(1968).
NIHAEBulletin1,No.2,pp.24-33.
pta,
d.R:etal(1972).NIHAE
Bulletin,5,261-290.
.WHO(1967).Techn.Rep:Ser.,No.350
n,
H.etal(1959),
Principlesof
Managemen,
MCGraw-
HO
(1973).Health
PracticeResearch,PublicHealthPapers9
46.
Knox,E.G.(1979).EpidemiologyinFlealthCarePlanning.Oxfo-
9OniversityPress.
47
Rao,K.N.(1966).TheNation'sHealth,ThePublicationsDivisic-
92

187. 984
HEALTHCAREOFTHE
COMMUNITY
Healthcare
Outputs
Health
care
System
Inputs
services
Healthstatusorhealth
problems
Public
Private
Voluntary
Indigenous
Changesin
healthstatus
Curative
Preventive
Promotive
Resources
FIG.
1
Modelofhealthcaresystem
TABLE
1
HEALTHSTATUSAND
HEALTH
PROBLEMS India:
Demographicprofile
Anassesmentofthehealthstatusandhealth
problems5is
thefirstrequisiteforanyplannedefforttodevelophealth
careservices.ThisisalsoknownasCommunity
Diagnosis.
Thedatarequiredforanalyzingthehealthsituationandfor
definingthehealthproblemscomprisethefollowing:
1.Morbidityandmortalitystatistics.
1,400miliom
Totalpopulation(2020)
20.0
Crudebirthrate(2020)
6.0
Crudedeathrate(2020)
1.2
Annualgrowthrate%(2020)
Populationdoublingtime
(atcurrentgrowthrate)
30years
2.Demographicconditionsofthepopulation.
66.5
Populationrural%(2017)
Adultliteracyrate
%(2011)
Densityofpopulationpersq.km(2020)
Sexratiofemaleper1000male(2016-18)
Populationbelow15years
%(2020)
Populationabove60years%(2017)
Averagefamilysize(2020)
Ageatmarriage,female(2018)
AnnualpercapitaGNP
(at
currentprices2018-19)
3
Environmentalconditionswhichhaveabearingon
health.
74.04
464
4
Socio-economicfactorswhichhaveadirecteffect
onhealth.
899
25.9
attitudes,beliefs,and
9.0
5.Culturalbackground,
practiceswhichaffecthealth.
1.8
6.Medicalandhealthservicesavailable.
22.3years
7.Otherservicesavailable.
Rs.126,521
Ananalysisofthehealthsituationinthelightofthe
abovedatawillbringoutthehealthproblemsandhealth
needsofthecommunity.Theseproblemsarethenranked
accordingtopriorityorurgencyforallocationofresources.
Abriefdescriptionofcurrentdemographicandmortality
profileandthehealthproblemsofIndia
isgiveninthe
followingpages.
Source:(23,24)
2.Mortalityprofile
Duringthelastfewdecades,therehasbeenanotable
improvementinthehealthstatusofthepopulation.
Thedeathratehassteadilydeclinedfrom21(1965)to
6.0(2020).Thelifeexpectancyatbirthhasgoneup
considerablysince1951,recordinganestimated67years
formalesand70yearsforfemalesduring2020.The
mortalityratesforanumberofinfectiousandcommunicable
diseaseshavealsoregisteredadecline(e.g.,cholera,
tuberculosis,malaria)
1.Demographicprofile
Amajorconcerntodayispopulationexplosion.The
demographicprofileischaracterisedby:
a.largepopulationbase;
b.highfertilitybothintermsofbirthrateandfamilysize;
C.lowordecliningmortality;
d."young"population(about28percentofthe
population)isbelowtheageofl5years;
etheproportionofilliteratepopulationiscloseto34.62
percent:thisexplainswhythedeclineinbirthratehas
beensoslow;and
f.dependencyratioof50.5percentfortheyear2018;
thatis,everyeconomicallyproductivememberhasto
supportalmostonedependant.
Table
1summarizesthemostrecentdemographic
informationavailable.
However,adeeperstudyrevealsdistressingsituation.
India'shealthstandardsarestilllowcomparedtothosein
developedcountries.Whileintheworldasawhole,the
IMK
fortheyear2018isabout29per1000livebirths,andinthe
developedcountriesaslowas5,inIndiaitisashighas32
Ourlifeexpectancyofabout68yearslagsbehindbyalmost
12-15yearscomparedtothatindevelopedcountrieswhere
itiscurrentlybetween71and80years.
Thecurrenturbandeathrate(during2018)was5.1and
theruraldeathrate6.7per1000ofpopulation.Therewer
alsoconsiderableinterstatevariationsindeathrate,asfo
example,during2018thedeathrateinChhattisgarh
was

188. HEALTHSTATUSAND
HEALTHPHOE
tothenationalaverageof
hghest,
abo
and7per1000livebirthsandMadhyaPradesh
about8.0.as
compared
19thFeb.2021,Indiareported1.09
millioncaseswth
Delhi.Amongthestates,Keralahadthe1,56,111deathsdueto
COVID-19.Largescalevecena
3.3in
driveisgoingoninthe
country.(f)Leprosy
eprO5y
15
another
imporfantpublichealth
probleminIridia.Duringthe
year2015-2016,totalof1,27,326newcasesweredetected
Outofwhichchildcaseswere9.49%and
deformitygradel
andabovewas4.14%.5148percentofthese
casesare
estimatedtobe
multibacillary.AlltheStatesandUnion
lerritoriesreportcasesofleprosy
However,there
are
Considerablevariationsnotonly
betweenoneState
arnd
another,butalsobetweenonedistrictand
another.Withthe
prevalencerateofabout0.68per10,000
population,
inidia
has
achievedthegoalofleprosy
eliminationatnational
level.
9)Filaria
:Theproblemoffilaríaremains
endemicinabout
255
districtsín16Statesand5UTs.The
popuiationatrisk
15
Over630
million.Toachieve
eliminationofLFtheGovtof
Indiahas
launched
nationwide
AnnualMassDrug
Administration
(MDA)withannual
single
recommended
doseof
diethylcar-bamazinecitrate
tabletsinadditionto
scalinguphomebasedfootcareand
hydrocele
operations.
In2014,250endemicdistricts
implernented
MDAtargetinga
populationofabout554millionwitha
coveragerateof87
percent.(h)AIDS:TheproblemofAIDSisstable.
Itis
estimatedthatbytheendofyear2017therewereabout2.1
millionHIVpositivecasesinthe
country.(i)Others
:Kala-
azar,meningitis,viralhepatitis,
Japanese
encephalitis.
denguefever,entericfeverand
helminthic
infestationsare
amongtheotherimportant
communicabledisease
problems
inIndia.Thetragedyisthatmostofthesediseasescanbe
eithereasilypreventedortreatedwithminimuminputof
resources.Infactmostofthe
developedcountriesofthe
worldhave
overcomemanyoftheseproblemsbysuch
measuresasmanipulationof
environment,
practiceof
preventivemedicineand
improvementofstandardsofliving.
stbighestIMRof48per1000livebirths(24)
owest
hadthe
Table2
showsthatthedeathedeathrateisthehighestintheage
1aDears.
Thisisasaresultofmalnutritionand
group
ection
15
to25percentottotaldeathsareattributedto
intectio
and
parasitic
diseases.
TABLE2
Child(Under5years)andinfantmortality
indicators,India2018
Indicators
Total RuralUrban
Child
mortalityrate
Infant
mortalityrate
Neo-natal
mortalityrate
Early
neo-natal
mortalityrate
Late
neo-natal
mortalityrate
Post
neo-natal
mortalityrate
Peri-natal
mortalityrate
Still
birthrate
36 40 26
32 36 23
23 27 14
18 20 10
5 3
9 9
22 25
14
4
Source:(23)
2
Healthproblems
The
HEALTHPROBLEMSofIndiamaybe
conveniently
groupedunderthe
followingheads:
1.
Communicablediseaseproblems;
2.
Non-communicablediseaseproblems;
3
Nutritionalproblems;
4.Environmentalsanitation
problems
5.Medicalcareproblems;and
6.Populationproblems.
04
154
9
.
2.
Non-communicablediseases
(NCDs)
Indiaisexperiencingarapid
epidemiologicaltransition
withalargeandrisingburdenofchronic
diseases,whici
wereestimatedtoaccountfor63percentofalldeaths
i
2016.NCDs,especiallydiabetesmellitus,CVDs,cance
stroke,andchroniclungdiseaseshaveemergedasmajc
publichealthproblemsduetoanageingpopulation
an
environmentally-drivenchangesinbehaviour.
1.Communicablediseaseproblems
13
Communicablediseasescontinuetobeamajorproblem
inIndia.Diseasesconsideredtobeofgreatimportancetoday
are:(a)Malaria:
Malariacontinuestobeamajorhealth
probleminIndia.Althoughtotalmalariacaseshasdeclined
comparedtopreviousyears,theproportionofPfalciparum
hasincreased.MalariacaseshaveincreasedinNorth-East
states,MadhyaPradesh,
Chhattisgarh,Jharkhand,Orissa,
AndhraPradesh,
Maharashtraetc.During2019therewere
0.34millioncasesofmalaria(whichincluded46.36%cases
ofPfmalaria)and73deaths.(b)Tuberculosis
luberculosisremainsapublichealthproblem,withIndia
accountingforone-fifthoftheworldincidence.Everyyear
about2.2millionpersonsdevelop
tuberculosis,ofwhich
about0.62millionarenewsmearpositivehighlyinfectious
Casesandabout0.24millionpeopledieof
1TBeveryyear.
Theemergenceof
HIV-TBco-infectionandmultidrug
resistantTBhasincreasedtheseverityandmagnitudeofthe
disease.InMarch2006
RNTCPhasachieved
nation-wide
coverage.(c)Diarrhoealdiseases
:Diarrhoealdiseases
constituteoneofthemajorcausesofmorbidityand
mortality,speciallyinchildrenbelow5yearsofage.Theyare
responsibleforabout13.19millioncasesofdiarrhoeaeach
year.Outbreaksofdiarrhoealdiseases(includingcholera)
ContinuetooccurinIndiaduetopoorenvironmental
Conditions.(d)ARI:Acuterepiratorydiseasesareoneofthe
majorcausesofmortalityand
morbidityinchildrenbelow5
yearsofage,During2018,41.996millionepisodesofARI
werereportedwith3,740deaths.(e)COVID-19:India
haad
tSshareofCOVID-19casesduringthepandemic,asof
Cancerhasbecomeanimportantpublichealthproble
inIndiawithanestimated1.1millionlakhcasesoccurri
ble
everyyear.Atanypointoftime,itisestimatedthatthere
a
nearly3.9millioncasesinthecountry.InIndia,tobac
relatedcancersaccountforabouthalfthetotalcanc
to
UP
amongmenand20%amongwomen.Aboutonemill
tobaccorelateddeathsoccureachyear,makingtoba-
relatedhealthissuesamajorpublichealthconcern.In
In=
morethen12millionpeopleareblind.Cataract(62.6
cent)isthemaincauseofblindnessfollowedbyRefrac
Error(19.70percent).Therehasbeenasigniticant
incr=
inproportionofcataractsurgerieswithIntraOcular
(IOL)implantationfrom<5percentin1994to95per
in2016-17.OralHealthCarehasnotbeengivensuffi-
importanceinourcountry.Mostofthedistricthospitals
apostofdentalsurgeonbuttheylackequipr
machinery,andmaterial.Evenwheretheequipment
e
themaintenanceispoor,henceservicedeliveryisaffea
The
able
eid
3.Nutritionalproblems
Fromthenutritionalpointofview,theIndiansocie
dualsociety,consistingofasmallgroupofwellfed
verylargegroupofundernourished.Thehigh
63

189. RESOURCES 987
lation:and(i)desiredoutputs.Thehealthneedsin
porobasedonthehealthsituationandhealthproblems
astuberculosiscontrol,leprosyeradicationandcontrolof
blindnessneededmoretrainedworkersandtechnicians.
Thusduringthepasldecademanynewcategoriesofhealfh
manpowerhavebeenintroduced.Theyincludevillage
health
urn
andaspirationsofthepeople.
Healthmanpowerplanningisanimportantaspectof
technicians,
rmmunityhealthplannin9.Itisbasedonaseriesof
acceptedratiossuchasdoctor-populationratio,nurse-
nopulationratio,bed-populationratio,etc.Theyaregivenin
Table
3.Thecountryisproducingannually,onanaverage
guides,multipurposeworkers,
ophthalmicassistants,etc.Table5givesthetotalhealth
manpowercurrentstockunderthe"ruralhealthscherne"
TABLE5
31.298allopathicdoctors,9,865Ayurvedicgraduates;
Healthman-powerinruralIndiaasonMarcli2019
1525Unanigraduates;320Siddhagraduatesand
12785Homoeopathicgraduates(26).
Category
Inposltion
TABLE3 1.
ANMatsub-centreandPHC
2:34,220
Suggestednormsforhealthpersonnel 2.MPW(Male)
59,348
13,786
HealthAssistant(Female)/LHV
HealthAssistant(Male)
8.
Categoryofpersonnel Normssuggested 13,446
4.
80,976
1per5,000population
NursingstaffatPHCandCHC
5.
1.Nurses
6.DoctorsinPHCs
29,799
2.Healthworker
femaleandmale
1per5,000populationinplain
areaand3,000population
intribalandhillyareas.
Generaldutymedicalofficersallopathic
atCHC
7.
15,395
3.Traineddai Oneforeachvillage
Specialists
7681per30,000populationinplain
areaand20,000population
intribalandhillyareas.
Providessupportive
super
visionto6healthworkers
4.Healthassistant,
(maleandfemale)
(a)Surgeon
(b)GynaecologistandObstetrician 1,351
683
(c)Physician
(d)Paediatrician
1,079
(male/female).
3,881
1per10,000population
1
per10,000population
1
per1,000population
TotalSpecialistsatCHC
Radiographer
5.Pharmacists
2,419
6.Lab.technicians
26,204
10.Pharmacist
11.Lab.Technician
12.BEE
7.ASHA
18,715
Source:(27) 3,7
Althoughtheaveragesaresatisfactoryonanational
basis,theyvarywidelywithinthecountry.Thereisalso
maldistributionofhealthmanpowerbetweenruraland
urbanareas.StudiesinIndiahaveshownthatthereissa
concentrationofdoctors(upto73.6percent)inurbanareas
whereonly26.4percentofpopulationlive.This
maldistributionisattributedtoabsenceofamenitiesinrural
Source:(41)
Moneyandmaterial
Moneyisanimportantresourceforprovidinghealth
services.Scarcityofmoneyaffectsallpartsofthehealth
deliverysystem.Inmostdevelopedcountries,average
governmentexpenditureforhealthisabout18percentof
GNP.Indevelopingcountriesitislessthan
1
percentofthe
GNPanditseldomexceeds2percentoftheGNP.This
translatesintoanaverageofa
fewdollarsperpersonper
yearintheunderdevelopedcountriesascomparedto
severalhundreddollarsindevelopedones.Tomakematters
worse,muchofthespendingisforservicesthatreachonlya
smallfractionofthepopulation.
areas,lackofjobsatisfaction,professionalisolation,lackof
ruralexperienceandinabilitytoadjusttorurallife.
Thenationalaveragesofdoctor-populationratio,
population-bedratioandnursetodoctorratioinsome
countriesareshowninTable4.
TABLE4
Healthmanpowerinsomecountries2010-2018
ToachieveHealthforAll,WHOhassetasagoalthe
expenditureof5percentofeachcountry'sGNPonhealth
care.
AtpresentIndiaisspendingabout3percentofGNP
onhealthandfamilywelfaredevelopment.
Nursesand
Midwives
per10000population
BedsDoctors
per10000
population
per10000
population
Country
7.0 20.9oIndia
Bangladesh
SriLanka
Thalland
Myanmar
7.8
Sincemoneyandmaterialarealwaysscarceresources
theymustbeputtothemosteffectiveuse,withaneyeon
maximumoutputofresultsforinvestment.Sincedeaths
frompreventablediseasessuchaswhoopingcough,
measles,tuberculosis,tetanus,diphtheria,malnutrition
frequentlyoccurindevelopingcountries,thecaseisstrong
forinvestingresourcesonpreventingthesediseasesrather
thanspendingmoneyonmultiplyingprestigiousmedical
institutionsandotherestablishmentswhichabsorbalarge
portionofthenationalhealthbudget(30).Management
techniquessuchascost-effectivenessandcost-benefit
analysisarenowbeingusedforallocationofresourcesinthe
fieldofcommunityhealth.
8.0
2.2
5.6
9.6
8.1
8.6
36.0
21.0
9.0
16.4
20.8
10.0
Source:(25)
Healthmanpowerrequirementsaresubjecttochange,
bothqualitativelyandquantitatively,asnewprogrammes,
projectsandphilosophiesareintroducedintothehealthcare
system.Forexample,therehasbeenachangefrom
unipurposetomultipurposestrategy.Thencamethegoalof
HealthforAll.Inaddition,nationalhealthprogrammessuch

190. 1000 HEALTHCAREOFTHECOMMUNITY
counsellingandservicesrelatedtosexualconcerns,
pregnancy,
contraception,abortion,
problemsetc.
Supportmanpower:
menstrual
Personnel Strength
Servicesfortetanusimmunizationofadolescents.
StaffNurse
PublicHealthNurse(PHN)
ANM
19**
Nutritionalcounselling,preventionandmanagement
ofnutritionalanaemia.
Pharmacist/compounder
Pharmacist-AYUSH
Lab.Technician
Radiographer
OphthalmicAssistant
Dresser(certifiedbyRedCross/
St.JohnsAmbulance)
WardBoys/NursingOrderly
Sweepers
Chowkidar
Dhobi
Mali
Aya
Peon
OPDAttendant
RegistrationClerk
StatisticalAssistant/DataEntryOperator
Accountant/Admin.Assistant
OTTechnician
STI/RTImanagement
ReferralservicesforVCTCandPPTCTservicesand
servicesforsafeterminationofpregnancy,itnot
availableatPHC.
211.Bloodstoragefacility.
12.Diagnosticservices:(a)Inadditiontothelab
facilitiesandX-ray,ECGshouldbemadeavailablein
theCHCwithappropriatetrainingtoanursingstaff
Lab/Technician;and(b)AIlnecessaryreagents,glass
wareandfacilitiesforcollectingandtransportof
samplesshouldbemadeavailable.
13.Referral(transport)services.
14.MaternalDeathReview(MDR).
Z
Manpowerforcommunityhealthcentres
Inordertoprovideroundtheclockclinicalservices,the
revisedIPHSstaffpatternisasfollows(37) Total 64
*WillbeappointedundertheASHAscheme.
**
ForprovidingroundtheclockserviceatOT,labourroom,casualty,
malewardandfemalewardalongwithprovisionofleavereserve.
|Personnel StrengthDesirableQualifications
BlockHealth
Officer
Seniormostspecialistsamong
thebelowmentioned
speciality(Physician/General
surgeon/Paed./Obs&Gyne
Anaesthesia/PublicHealth/
Ophthalmology)
MS/DNB,(GeneralSurgery)
5.HEALTHANDWELLNESSCENTRES(41)
TheNationalHealthPolicy,2017recommended
strengtheningthedeliverysystemofprimaryhealthcare,
throughestablishmentof"HealthandWellnessCentres
(HWCs)"astheplatformtodelivercomprehensiveprimary
healthcare.GovernmentofIndiaiscommittedtowards
creationof1,50,000Health&WellnesCentres(HWCs)by
transformingexistingSub-centres(SCs)andPrimaryHealth
Centres(PHCs)asbasicpillarsofAyushmanBharatto
deliverComprehensivePrimaryHealthCare(CPHC)
ThesecentresdeliverCPHCbringinghealthcarecloserto
thehomesofpeople,coveringbothmaternalandchild
healthservicesandnon-communicablediseases,including
freeessentialdrugsanddiagnosticservices.Theemphasisot
healthpromotionandpreventionisdesignedtobringfocus
onkeepingpeoplehealthybyengagingandempowering9
individualsandcommunitiestochoosehealthybehaviours
andmakechangesthatreducetheriskofdevelopingchronic
diseasesandmorbidities.
GeneralSurgeon1
Physician MD/DNB,(GeneralMedicine)
MD/DNB/DGO(OBG)Obstetrician&
Gynaecologist
Paediatrics MD(Paediatrics)/DNB/DCH
Anaesthetist MD(Anaesthesia)/DNB/DA/
Certificatecoursein
Anaesthesiaforoneyear
PublicHealth
Manager
1 MD(PSM)/MD(CHAJMD
CommunityMedicineorPost
GraduationDegreewithMBA
MD/MS/DOMS/DNB/
(Ophthal)
Eyesurgeon
(1
everyfive
CHCs)
for
DentalSurgeon
1
GeneralDuty6
MedicalOfficer(atleast
2female
doctors)
ToensuredeliveryofCPHCservices,existingSCs
coveringapopulationof3000-5000wouldbeconvertedto
HWCs,withtheprinciplebeing"timetocare"tobenomore
than30minutes.PHCsinruralandurbanareaswouldalis0
beconvertedto'HWC.Suchcarecouldalsobeprovided
complementedthroughoutreachservices,mobilemedical
units,camps,homeandcommunity-basedcare,butthe
principleshouldbeaseamlesscontinuumofcarethat
ensurestheprinciplesofequity,universalityandnofinancial
hardship.
BDS
MBBS
Specialistof
AYUSH
1 PostGraduateinAYUSH
GeneralDuty1
MedicalOffier
ofAYUSH
GraduateinAYUSH SC-HWCteam
TheHWCattheSClevelwouldbeequippedandstafted
byanappropriatelytrainedprimaryhealthcareteam.
comprisingofmulti-purposeworkers(maleandfemale)*
Total
15/16

191. JOB
DESCRIPTION OFMEMBE5
OF
THEMEALTHHTEAA1001
4SHAs,andled
Togetheithey
willde
byaMid-LevelHealthProvider(MLHP).
deliveranexpandedrangeofservices.In
earlierbeenupgradedtoadditional
allendingtopatientsintheout-door;intheafternoon
hesupervisesthefieldwork.
ome
states,SCshave
2.Histourprogrammeissodesignedastocoverallthe
basichealthservices
includingfamilyplanning.
3.HewillplanandimplementUIPasperguidelinesand
ensuremaximumpossiblecoverageofthepopulation
inthePHC.Hewillensureproperstorageofvaccine
andmaintenanceofcoldchainequipment.Hewill
ensureadequatesuppliesofvaccineand
miscellaneous
itemsrequiredfortheeffectiveimplementationofOIP
4.HewillensureproperimplementationofIMNCIasper
guidelines.
HWCS.
PHCthat
islinkedtoaclusterofHWCswouldserveas
h
firstpoint
ofreterraltormanydiseaseconditionsforthe
uWCs
initsjurisdiction.Inaddition,itwouldalsobe
PHCS.SuchadditionalPHCSwillalsobetransformedto
edasaHWCtodelivertheexpandedrangeoftrengthene0
primarycareservices.
PHCIUPHC-HWCteam
The
MedicalOfficeratthePHCwouldberesponsiblefor
ensuringthatCPHCservicesaredeliveredthroughallHWCs
inher/hisareaandthroughthePHCitself.Thenumberand
oualificationsofstaffatthePHCwouldcontinueasdefined
in
theIndianPublicHealthStandards(IPHS).
5.HewillvisitschoolsinthePHCareaatregular
intervalsandarrangeformedicalcheckupand
immunization.
6.Hewillorganizeandconducttubectomyand
vasectomycamps.
Expandedservices
TheHWCwoulddeliveranexpandedrangeofservices.
TheseserviceswouldbedeliveredatbothSub-centreandin
thePHCs.whicharetransformedasHWCs.Thelevelof
complexityofcareofservicesdeliveredatthePHCwouldbe
higherthanattheSub-centrelevelandthiswouldbe
indicatedinthecarepathwaysandstandard
treatment
guidelines.
7.Organizetrainingofallheath
personnellikeASHA,
anganwadiworker,Daisetc.
8.Heensuresthatnationalhealthprogrammesarebeing
implementedinhisareaproperly.
9.Hevisitseachsubcentreregularlyonfixeddaysand
hoursandprovidesguidance,supervisionand
leadershiptothehealthteam.
10.Hespendsonedayineachmonthorganisingstaff
meetingsatiheprimaryhealthcentretodiscussthe
problemsandreviewtheprogressofhealthactivities
11.Thesuccessofaprimaryhealthcentredepends
largelyontheteamleadershipwhichthemedical
officerisabletoprovide.Themedicalofficermustbe
theplanner,thepromoter,thedirector,thesupervisor,
thecoordinatoraswellastheevaluator.
Theexpandedrangeofservicesareasfollows:
1.Careinpregnancyandchild-birth.
2.Neonatalandinfanthealthcareservices.
3.Childhoodandadolescenthealthcareservices.
4.Familypanning,contraceptiveservicesandother
reproductivehealthcareservices.
5.Managementof
communicablediseasesincluding
nationalhealthprogrammes. SecondMedicalOfficer
6.Managementofcommon
communicablediseasesand
out-patientcareforacutesimpleillnessesandminor
Thesecondmedicalofficerperformsidenticalduties.
ailments.
2.HealthworkerMaleandFemale
1.Screening,prevention,controlandmanagementofnon-
communicablediseases.
UnderTheMultipurposeWorkerScheme,onehealth
workerfemaleandonehealthworkermalearepostedat
eachsub-centreandareexpectedtocoverapopulationof
5000(3000intribalandhillyareas).However,health
workerfemalelimitsheractivitiesamong350-500families.
8.CareforcommonophthalmicandENTproblems.
9.Basicoralhealthcare.
10.Elderlyandpalliativehealthcareservices.
A.HEALTHWORKERFEMALE(ANM)
11.Emergencymedicalservices.
12.Screeningandbasic
managementofmentalhealth
ailments.
Shewillcarryoutthefollowingfunctions:
1.MaternalandChildHealth
1.1Registerandprovidecaretopregnantwomen
throughouttheperiodofpregnancy.
Thefirsthealthandwellnesscentrewasinauguratedby
thePrimeMinisteron14thApril2018atatBijapur,
Chhattisgarh.Ason31stMarch2019,therewere17,895
HWCs,functionalinIndia.Outofthese7,821areHWC-SCs
rural);98HWC-SCs(urban);8,242
HWC-PHCs(rural)and
1,734HWC-PHCs(urban)arefunctional(41).
1.2Ensurethateverypregnantwomanmakesat
least4(lour)visitsforantenatalcheck-up
accordingtosuggestedschedule.
1.3Testurineofpregnantwomenforalbuminand
sugar,Estimatehaemoglobinlevel.
1.4ReferallpregnantwomentoPHCforRPRtest
forsyphilis.
1.5Refercasesofabnormalpregnancyandcases
withmedicalandgynaecologicalproblemsto
HealthAssistantFemale(LHV)orthePrimary
HealthCentre.
JOB
DESCRIPTIONOF
MEMBERSOF
THEHEALTHTEAM
1.MedicalOfficer,PHC
L.Heisthecaptainofthehealthteamattheprimary
healthcentre.Hedevotesthemorninghours