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COMMUNITY MEDICINEwith
Recent AdvancesFourth Edition
AH Suryakantha MD DHA Professor
Department of Community MedicineBasaveshwara Medical College and Hospital
Chitradurga, Karnataka, India
Formerly, Professor and Head Department of Community Medicine
JJM Medical College Davangere, Karnataka, India
Formerly, Professor Department of Community Medicine
SS Institute of Medical Sciences and Research Center Davangere, Karnataka, India
New Delhi | London | Philadelphia | Panama
The Health Sciences PublisherJa
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Review
As a reviewer of this book I would like to congratulate Dr. AH Suryakantha for publishing fourth edition and contributing in professional growth. Community Medicine is the vast subject which includes emerging health problems and reemerging diseases.
is book gives comprehensive knowledge of all required topics as per the syllabus. Author has organized the content is systematic way. It includes colour plates. It also has current information on global warming, reemerging diseases etc. It includes IMNCI modules which will be great help for the students to learn about it in detail.
I have few suggestions like, colour plates should be included in appendices instead of in front pages. Page set up needs to be corrected as there is repetition of some pages . e book can be published in two volumes as it has many pages which make it difficult to carry or handle it easily.
Overall the efforts put by the author are appreciable & commendable. I wish the author all the best for the success of this book.
anks for giving the opportunity to review the book on Community Medicine with Recent Advances.
Dr. Anita Yuvaraj NawaleAssistant Professor,Bharati Vidyapeeth College of Nursing, PuneEmail –[email protected]
Salient Features
Student-friendly and teacher-friendly book.
Comprehensively covers the syllabus as recommended by the university.
Cover page reminds some of the great stalwarts, who have contributed to the public health in terms of lives that can be saved.
Exquisite charts, diagrams and pictures with lucid language make the reading a pleasurable experience.
Topics covered in the annexures are some Stalwarts and their contribution to community medicine, Calendar of important dates and events, Milestones in Vaccination, List of world breastfeeding week theme since 1992, List of world health day theme, and Goals to be achieved by 2000-2015.
Useful for public health professionals and policy-makers.
Gives the researchers a thought to work in terms of preventing the disease and promoting the health, thus serving the community.
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How this Book is Useful?What’s New
oroughly revised and updated with recent advances.
Chapter on Communicable Diseases, now contains revised case de�nitions of tuberculosis and their treatment outcomes; bene�ts of directly observed treatment short-course (DOTS); Revised National Tuberculosis Control Program (RNTCP) laboratory network; childhood tuberculosis; global multidrug-resistant tuberculosis (MDR-TB) crisis; antiretroviral treatment in HIV; revised WHO clinical staging of HIV disease in infants and children; cotrimoxazole prophylaxis for HIV-related infections among children, adolescents and adults; prevention of parent-to-child transmission of HIV; revised guidelines for postexposure prophylaxis for HIV; epidemiology of hepatitis C; commitment of measles elimination by 2020; maternal and neonatal tetanus elimination; diagnosis and treatment of malaria; malaria control strategies; malaria vaccine; dengue vaccine; revised National and Indian Academy of Pediatrics (IAP) immunization schedule.
Chapter on Preventive Obstetrics and Pediatrics, now contains revised guidelines on antenatal care; National Health Mission with all its components such as Reproductive, Maternal, Newborn, Child Health and Adolescent (RMNCH+A) strategy India, Newborn Action Plan, Janani Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram (JSSK), Navajatha Shishu Suraksha Karyakram, Rashtriya Bal Swasthya Karyakram, Rashtriya Kishor Swasthya Karyakram, Rogi Kalyan Samiti, National Rural Health Mission (NRHM) and new scheme of National Urban Health Mission.
Other minor topics are National Family Planning Indemnity Scheme and Preconception and Prenatal Diagnostic Technique Act, 1994.
Millennium development goals (MDGs) and sustainable development goals for 2015–2030 have been described in detail.
Chapter on National Health Programs now includes control programs on �uorosis, viral hepatitis, health care of the elderly and Global Polio Eradication Initiative and End Game Strategic Plan.
e National AIDS Control Program, Tobacco Control Program and guidelines for the control of iron de�ciency anemia have been revised.
Some topics of the National Programs have been integrated with the respective chapters to avoid fragmentation and enhance learning.
e international public health problems, such as middle-east respiratory syndrome, Ebola virus disease and Zika disease, have been added to the chapter on Emerging Diseases.
Other small topics incorporated are e-toilet, Mission Indradhanush, national iron plus initiative, demographics of India, adverse events following immunization, modi�ed BG Prasad’s classi�cation of socioeconomic status and many others.Ja
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It gives me immense pleasure with professional satisfaction to bring forth the fourth edition, with the same elegant cover page.As the field in this subject is growing, so is the transition in the book. As per the title, recent advances in community medicine
have been incorporated. The chapter on Communicable Diseases, now contains revised case definitions of tuberculosis and their treatment outcomes; benefits of directly observed treatment short-course (DOTS); Revised National Tuberculosis Control Program (RNTCP) laboratory network; childhood tuberculosis; global multidrug-resistant tuberculosis (MDR-TB) crisis; antiretroviral treatment in HIV; revised WHO clinical staging of HIV disease in infants and children; cotrimoxazole prophylaxis for HIV-related infections among children, adolescents and adults; prevention of parent-to-child transmission of HIV; revised guidelines for postexposure prophylaxis for HIV; epidemiology of hepatitis C; commitment of measles elimination by 2020; maternal and neonatal tetanus elimination; diagnosis and treatment of malaria; malaria control strategies; malaria vaccine; dengue vaccine; revised National and Indian Academy of Pediatrics (IAP) immunization schedule.
The chapter on Preventive Obstetrics and Pediatrics, now contains revised guidelines on antenatal care; National Health Mission with all its components such as Reproductive, Maternal, Newborn, Child Health and Adolescent (RMNCH+A) strategy India, Newborn Action Plan, Janani Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram (JSSK), Navajatha Shishu Suraksha Karyakram, Rashtriya Bal Swasthya Karyakram, Rashtriya Kishor Swasthya Karyakram, Rogi Kalyan Samiti, National Rural Health Mission (NRHM) and new scheme of National Urban Health Mission. Other minor topics are National Family Planning Indemnity Scheme and Preconception and Prenatal Diagnostic Technique Act, 1994. Millennium development goals (MDGs) and sustainable development goals for 2015–2030 have been described in detail.
The chapter on National Health Programs now includes control programs on fluorosis, viral hepatitis, health care of the elderly and Global Polio Eradication Initiative and End Game Strategic Plan.
The National AIDS Control Program, Tobacco Control Program and guidelines for the control of iron deficiency anemia have been revised. Some topics of the National Programs have been integrated with the respective chapters to avoid fragmentation and enhance learning. The international public health problems, such as middle-east respiratory syndrome, Ebola virus disease and Zika disease, have been added to the chapter on Emerging Diseases.
Other small topics incorporated are e-toilet, Mission Indradhanush, national iron plus initiative, demographics of India, adverse events following immunization, modified BG Prasad’s classification of socioeconomic status and many others.
Almost all the typographical errors happened in third edition have been taken care of. All this was possible because of the feedback I received from my colleagues from various parts of the country. It is indeed a pleasure to receive both positive and negative feedback from the readers to effect improvement in the subsequent editions.
My special thanks to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President), Mr Tarun Duneja (Director-Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for the encouragement given to me and to make the book popular both at the national and international levels. I am grateful to all undergraduate and postgraduate students, who have helped me to keep the book up-to-date.
I sincerely thank Mr Venugopal V, Associate Director of Jaypee Brothers Medical Publishers (P) Ltd., South India Zone, who inspired me to take up the task and go ahead.
I also thank to Dr Nagendra Gowda, Professor and Head, Department of Community Medicine, Basaveshwara Medical College and Hospital, Chitradurga, Karnataka, India, for his kind cooperation extended in completion of the book.
I sincerely thank Late Dr Suresh Babu, Ex. Dean of Basaveshwara Medical College and Hospital, Chitradurga, for providing me an opportunity to write the fourth edition.
I also thank Mrs Usha Suryakantha for her cooperation throughout the period of my work.I will be failing in my duty, if I do not thank Mr Sanjeev Kumar GP, M/s Gundal Compu Center, Davangere, Karnataka, India,
for his valuable help in preparing the manuscript.
AH Suryakantha
Preface to the Fourth Edition
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Section 1: Basic Concepts of Community Medicine
1. Introduction to Community Medicine 3Hygiene 3 • Preventive Medicine 3 • Social Medicine 4 • Community Diagnosis 4
2. Concept of Health 6Physical Dimension 6 • Mental Dimension 6 • Social Dimension 6 • Spiritual Dimension 6 • Emotional Dimension 6 • Vocational Dimension 7 • Positive Health 7 • Well-being 7 • Human Development Index 7 • Spectrum of Health 8 • Determinants of Health 8 • Indicators of Health 9
3. Concept of Disease 12Theories of Disease Causation 12 • Epidemiological Triad 13 • Natural History of Disease 13 • Iceberg Phenomenon of Disease 15
4. Concept of Prevention 17Primary Prevention 17 • Primordial Prevention 18 • Secondary Prevention 19 • Tertiary Prevention 19
Section 2: Environment and Health
5. Environment and Water 23Physical Environment 23 • Biological Environment 23 • Social Environment 23 • Cultural Environment 23 • Water 23 • Water Cycle 24 • Well 24 • Health Hazards of Water Contamination 26 • Purification of Water 27 • Hardness of Water 38 • Conservation of Water Resources 40 • Sanitary Analysis of Water 40 • Laboratory Examination of Water 41
6. Air and Ventilation 46Changes in the Air Due to Human Occupancy 46 • Effects of Vitiated Air 46 • Indicators of Thermal Comfort 46 • Air Pollution 48 • Prevention and Control of Air Pollution 49 • Ventilation 50
7. Noise 52Noise Level Values 52 • Instruments Used in the Study of Noise 52 • Hazards of Noise Pollution 53 • Prevention and Control of Noise Pollution 53
Contents
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Community Medicine with Recent Advancesxii
8. Light 54Measurement of Light 54 • Natural Lighting 54 • Artificial Lighting 54 • Health Hazards of Lighting 55
9. Radiation 56Nonionizing Radiations 56 • Ionizing Radiations 57 • Prevention and Control of Radiation Hazards 60
10. Housing 62Requirements of a House 62 • Housing Standards 62 • Housing and Health 63 • Indicators of Housing 64 • Housing Problem 64
11. Meteorology 66Atmospheric Pressure 66 • Air Temperature 68 • Humidity 71 • Air Movement 72
12. Disposal of Wastes 75Refuse 75 • Methods of Refuse Disposal 75 • Recycling of Refuse 77 • Disposal of Excreta 77 • e-Toilets 84 • Water Carriage System (Sewerage System) 85 • Disposal of Sullage 87 • Disposal of Sewage (Sewage Treatment) 88
13. Management of Hospital Waste 93Characteristics of Health Care Waste 93 • Quantity of Health Care Waste 93 • Objectives of the Waste Management System 94 • Safe Waste Management Practices Helps 94 • Legislative Framework 94 • Strategies Adopted for Hospital Waste Management 95 • Available Treatment and Disposal Technologies 98 • Newer Technologies 98 • Do’s and Don’ts of Health Care Waste 105
14. Electronic Waste Management 108E-waste Burden Globally 108 • Burden in India 108 • Sources of E-waste 109 • Impacts/Hazards of E-waste 109 • Basel Convention 110 • Waste Minimization Techniques 111 • Management of Options 111 • E-waste Disposal 111
15. Medical Entomology 113Classification of Arthropods 113 • Arthropod Borne Diseases 114 • Principles of Arthropod Control 115 • Class Insecta 115 • Mosquitoes 115 • Flies 127 • Fleas 134 • Lice 138 • Bugs 140 • Class Arachnida 141 • Ticks 141 • Mites (Chiggers) 144 • Class Crustacea 148 • Cyclops (Water Flea) 148 • Disinsection 149 • Insecticide Toxicity 151
Section 3: Nutrition and Health 16. Nutrition and Health 155
Classification of Foods 155 • Nutrients 156 • Macronutrients 156 • Proteins 156 • Fats 158 • Carbohydrates 159 • Micronutrients 160 • Vitamins 161 • Fat Soluble Vitamins 161 • Water Soluble Vitamins 164 • Minerals 167 • Other Trace Elements 171
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• Food Groups 172 • Energy Requirements 178 • Balanced Diet 180 • Food Hygiene 180 • Food-related Diseases (Public Health Nutrition Problems) 187 • Deficiency Diseases 188 • Guidelines for the Control of Iron Deficiency Anemia National Iron Plus Initiative 194 • Excess of Food Consumption 201 • Food-borne Intoxications 201 • Food Poisoning 204 • Food-borne Diseases 206 • Diet Survey 210 • Indicators of Malnutrition 211 • Nutritional Surveillance 211 • National Nutrition Policy 212 • Annexure 213
Section 4: Occupational Health 17. Occupational Health 219
Burden of Occupational Diseases 219 • Ergonomics 220 • Occupational Hazards 220 • Pneumoconioses 222 • Lead Poisoning (Plumbism) 226 • Occupational Cancers 229 • Occupational Dermatoses 230 • Occupational Health in Agricultural Industry 231 • Hazards due to Industriali zation and Urbanization 232 • Accidents in Industries 232 • Offensive Trades and Occupations 233 • Sickness Absenteeism 234 • Women in Industry 235 • Health Status of Industry 236 • Prevention and Control of Occupational Hazards 236 • Legislation 239 • Social Security 243
Section 5: Epidemiology 18. Principles and Practice of Epidemiology 247
Epidemiology 247 • Objectives of Epidemiology 247 • Epidemiological Approach 248 • Scope of Epidemiology 248 • Measurement of Morbidity 249 • Measurement of Mortality 251 • Epidemiological Studies (Methods) 255 • Time Distribution 255 • Place Distribution 257 • Person Distribution 258 • Analytical Studies (Analytical Epidemiology) 259 • Experimental Epidemiology (Experimental Epidemiological Studies) 266 • Nonrandomized Trials 268 • Association and Causation 269 • Uses of Epidemiology 271
19. Epidemiology of Infectious Diseases 273Commonly used terms 273 • Surveillance 275 • Dynamics of Disease Transmission 278 • Incubation Period 281 • Investigation of an Epidemic Disease 283 • Prevention and Control of an Epidemic Disease 284 • Immunizing Agents 286 • Immunization Program 290 • Mission Indradhanush 297 • Cold-chain 298 • Screening for Disease 304 • Disinfection 308 • Disinfection Procedures 314 • Hospital-acquired Infections (Nosocomial Infections) 315 • Emporiatrics 317 • International Health Regulations, 2005 318
20. Epidemiology of Communicable Diseases 320Air-borne Diseases 320 • Story of Smallpox (Variola Major) (Obituary) 320 • Human Monkeypox 321 • Chickenpox (Varicella; Waterpox) 321 • Acute Respiratory Infections 324 • Measles (Morbilli; Rubeola) 327 • Commitment of Measles Elimination by 2020: Challenges in India 331 • German Measles (Rubella) 334 • Mumps 336 • Influenza 337 • Diphtheria 353 • Whooping Cough (Pertussis) 358
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Community Medicine with Recent Advancesxiv
• Meningococcal Meningitis (Cerebrospinal Fever or Cerebrospinal Meningitis) 360 • Tuberculosis 363 • Revised Case Definitions of Tuberculosis and their Treatment Outcomes 376 • Childhood Tuberculosis 383 • Tuberculosis and HIV 387 • Recent Advances in Multidrug Resistant TB Cases and Revised National Tuberculosis Control Program 388 • Five Priority Actions to Address the Global MDR-TB Crisis 391 • Severe Acute Respiratory Syndrome 393 • Water-borne Diseases 398 • Typhoid Fever 398 • Acute Diarrheal Diseases 402 • Cholera 409 • Viral Hepatitis 413 • Poliomyelitis 421 • Dracunculiasis 428 • Amebiasis 430 • Giardiasis 432 • Soil-borne Diseases 434 • Ascariasis 434 • Ancylostomiasis 435 • Tetanus 438 • Neonatal Tetanus 443 • Vector-borne Diseases 444 • Malaria 444 • Malaria Control Strategies 453 • Malaria Vaccine 454 • Lymphatic Filariasis 455 • Plague 462 • Leishmaniases 466 • Arboviral Diseases 468 • Yellow Fever 468 • Dengue Fever 471 • Japanese Encephalitis 474 • Chikungunya Fever (Epidemic Polyarthritis) 478 • Kyasanur Forest Disease 479 • Rickettsial Diseases 482 • Epidemic Typhus 482 • Endemic Typhus 483 • Scrub Typhus 483 • Indian Tick Typhus 484 • Rocky Mountain Spotted Fever 484 • Rickettsial Pox 484 • Trench Fever 484 • Q-Fever 484 • Sexually Transmitted Infections 486 • Extent of the Problem 486 • Syndromic Case Management of RTIs/STIs (Syndromic Approach) 489 • Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome 498 • History 498 • Magnitude of the Problem 499 • India 499 • Antiretroviral Treatment 508 • AIDS Vaccine 511 • Clinical Trial on AIDS Vaccine 512 • Postexposure Prophylaxis for HIV 514 • Prevention of Parent to Child Transmission of HIV in India 516 • Cotrimoxazole Prophylaxis for HIV-related Infections Among Children, Adolescents and Adults 519 • Surface Infections 521 • Rabies 521 • Leprosy 532 • Control of Leprosy 545 • Standard Child Treatment Regimen (10–14 years) 546 • Yaws 552
21. Epidemiology of Noncommunicable Diseases 555Noncommunicable Diseases 555 • Future Plan to Prevent and Control Noncommunicable Diseases 556 • Cardiovascular Diseases 559 • Coronary Artery Disease Ischemic Heart Disease 559 • Congenital Heart Diseases 561 • Rheumatic Heart Disease 562 • Hypertension 564 • Stroke 567 • Obesity 569 • Cancer 572 • Magnitude 572 • Distribution 572 • Risk Factors 572 • Pre-existing Conditions 573 • Prevention and Control 574 • Epidemiology of Cancer Cervix 574 • Diabetes Mellitus 577 • Classification 577 • Indian Diabetic Risk Score (IDRS)(Developed by Madras Diabetes Research Foundation) 580 • Accidents 583 • Global Problem 583 • India 583 • Measurements of Accidents and Injuries 583 • Agent Factors 584 • Host Factors 584 • Other Factors 584 • Environmental Factors 584 • Prevention 585 • Blindness 585 • Extent of the Problem 585 • Host Factors 586 • Environmental Factors 586 • Other Factors 586 • Prevention and Control 586 • Other Preventive Measures 587 • Vision 2020: The Right to Sight 587 • Mobility of Blind 588 • Community Ophthalmology 589
Section 6: Health-related Disciplines 22. Maternal and Child Health Services (Preventive Obstetrics and Pediatrics) 595
Mother and Child—One Unit 595 • Services to the Mothers 596 • Antenatal Care (Care of the Mother During Pregnancy) 596 • Essential and Immediate Care of the Newborn 610
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• Low Birth Weight Baby 613 • Kangaroo Mother Care 615 • Feeding of Infant 618 • Relactation 624 • Induced Lactation 625 • Growth Monitoring 627 • Under Five Clinics 630 • Handicapped Children 631 • Juvenile Delinquency 633 • Child Guidance Clinic 633 • School Health Services 634 • Indicators of MCH Care 637 • Rights of the Child 643 • Child Welfare Agencies 644 • Integrated Mother and Child Development Services Scheme (IMCDS Scheme) 644 • Street Children 648
23. Demography 651
Demographic Cycle (Demographic Stages) 651 • Size of the Population (Magnitude of the Population) 652 • Population Trend in the World 653 • Population Trend in India 653 • Composition of the Population 653 • Demographics of India 657 • Distribution of the Population 658 • Population Dynamics 658 • Measurement of Fertility (Fertility Indicators) 659 • Measurement of Mortality 661 • Population Explosion (Population Bomb) 662 • Population Stabilization 663
24. Family Planning 665
Need for Family Planning 665 • Scope of Family Planning Services 666 • Contraceptive Methods (Fertility Regulating Methods; Techniques of Birth Control) 667 • Temporary Methods 667 • Terminal Methods 686 • Male Contraception 688 • Evaluation of Contraceptive Methods 689
25. Biostatistics 691
Variability 691 • Applications of Biostatistics 691 • Presentation of Statistical Data 692 • Measures of Central Tendency 701 • Measures of Location: Quantiles 703 • Measures of Dispersion 704 • Probability 707 • Sampling 710 • Sampling Variation 714 • Null Hypothesis (Denoted as H0) 715 • Tests of Significance 716 • Analysis of Variance 726 • Nonparametric Tests 726 • Correlation and Regression Correlation 727 • Regression 729 • Life Table 731
26. Social Science 738
Community 739 • Culture 739 • Acculturation 739 • Family System 739 • Family Cycle 739 • Family Types 740 • Family Functions 741 • Role of Family and Cultural Factors in Health and Disease 741 • Social Process 743 • Social Factors in Health and Disease (Social Pathology) 748 • Management or Prevention of Social Pathology 751 • Social Research 752 • Operational research 755 • Medicosocial Worker 755 • Personal Hygiene 756
27. Information, Education and Communication 758
Information 758 • Education 758 • Communication 758 • Steps in IEC: Planning, Implementation and Evaluation 759 • Types of Communication 759 • Barriers of Communication 760 • Health Education 760 • Approaches in Health Education 760 • Contents of Health Education 761 • Practice in Health Education 762 • Methods in Health Education 762 • Lecture 763 • Demonstration 764 • Demerits 764 • Delphi Method 767
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Community Medicine with Recent Advancesxvi
28. Human Genetics 769Multiplication 769 • Chromosomes 770 • Chromosomal Abnormalities 770 • Deoxyribonucleic Acid 770 • Population Genetics 771 • Classification of Genetic Disorders 771 • Prevention and Control of Hereditary Disorders 773
29. Preventive Geriatrics 775Population of the Aged 775 • Theories of Aging Process 776 • Health Problems of the Aged 776 • Care of the Aged 777 • Old Age Social and Income Security 778 • Helpage India 779 • National Policy on Older Persons 779 • Benefits Given to Senior Citizens of India 779
30. Mental Health 781Magnitude of the Problem 781 • Causative Factors 781 • Types of Mental Disorders 782 • Prevention and Control of Mental Illness 782
31. Adolescent Health 784Changes During Adolescence 784 • Importance 784 • Challenges in Adolescent Health in India 785 • Impacts of Adolescence 785 • Adolescent Health Problems 785 • Services in Adolescent Health Clinics 786 • Recommendations 786 • Adolescent Reproductive and Sexual Health 786
32. Alcoholism and Drug Addiction 789Identification of Drug Abusers 790 • Dependence Producing Drugs 790 • Prevention and Control of Drug Abuse 792
Section 7: Health Administration and Organization 33. Health for All 795
Meaning 795 • Historical Perspective 795 • Importance 795
34. Millennium Development Goals 798
35. Sustainable Development Goals 812Background 812 • Health Goal and Health Targets 814
36. Health Care 815Three-tier System of Health Care 815 • Primary Health Care 816 • Public Health Sectors 818 • Indian Public Health Standards for Primary Health Centers 821 • Health Worker Female 824 • Health Worker Male 826 • Health Assistant Female 827 • Health Assistant Male 827 • Indian Public Health Standards for Community Health Centers 828 • Indigenous System of Medicine 830
37. National Health Mission 831Components of National Health Mission 831 • Reproductive Maternal Neonatal Child Health + Adole scent Health 831 • India Newborn Action Plan 832
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• Janani Suraksha Yojana 840 • Janani Shishu Suraksha Karyakram 842 • Navjaat Shishu Suraksha Karyakram 843 • Rashtriya Bal Swasthya Karyakram 844 • Rashtriya Kishor Swasthya Karyakram 845 • Operationalization of the Interventions of RKSK 846 • Rogi Kalyan Samiti 847 • National Rural Health Mission: 2005–2012 849 • National Urban Health Mission 853 • National Urban Health Mission—New Scheme 857
38. Health Planning and Management 858Planning 858 • Management (Network Analysis) 859 • Cost Benefit Analysis 861 • Cost-effective Analysis 861 • Manager 861
39. National Health Planning 863Bhore Committee Report, 1946 863 • Mudaliar Committee Report, 1962 863 • Chadah Committee Report, 1963 864 • Mukherjee Committee Report, 1965 864 • Mukherjee Committee Report, 1966 864 • Jungalwalla Committee Report, 1967 864 • Kartar Singh Committee Report, 1973 864 • Srivastav Committee Report 865 • National Developmental Plans 865 • Twelfth Five-year Plan (2012–2017) 867 • Organization of Indian Health Administration 868 • Rural Development 871
40. National Health Policy 872Priority Areas of the Policy 872 • National Health Policy, 2002 873 • National Housing Policy 873 • National Nutrition Policy 873 • National Population Policy–2000: An Overview 874 • National Policy for Children—2013 875 • National Policy for Older Persons 877 • National Mental Health Policy of India 877
41. National Voluntary Health Agencies/Organizations 881Voluntary Health Agencies 881 • Voluntary Health Association of India 882 • Voluntary Health Agencies in India 882
42. International Health Organizations 884First International Sanitary Conference (1851) 884 • Pan American Sanitary Bureau (1902) 884 • Office International d’Hygiène Publique (1907) 884 • Health Organization of the League of Nations (1923) 885 • United Nations Relief and Rehabilitation Administration 885 • World Health Organization 885 • UNICEF 888 • United Nations Development Program 889 • Food and Agricultural Organization 889 • International Labor Organization 890 • United Nations Fund for Population Activities 890 • United Nations Educational Scientific and Cultural Organization 890 • United Nations High Commission for Refugees 890 • World Bank 890 • United Nations Joint Program on AIDS 891 • United Nations International Drug Control Program 891 • United Nations Environment Program 891 • International Atomic Energy Agency 891 • World Food Program 891
43. Bilateral Agencies 892Colombo Plan 892 • United States Agency for International Development 892 • Swedish International Development Cooperation Agency 892 • Danish International Development Agency 892 • Nongovernment (Non-UN) Agencies 893 • Cooperative for American Relief Everywhere 893 • Red Cross 894
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44. National Health Programs 896Related to Communicable Diseases 897 • Related to Noncommunicable Diseases 897 • Related to Nutrition 897 • Other Health Programs 897 • National Antimalaria Program 898 • National Malaria Eradication Program 898 • Revised Malaria Control Strategies 903 • National Framework for Malaria Elimination (NFME) 903 • National Filaria Control Program 904 • National Kala-azar Control Program 906 • National Japanese Encephalitis Control Program 906 • National Dengue Fever/Dengue Hemorrhagic Fever Control Program 906 • National Leprosy Control Program 906 • National Leprosy Eradication Program 907 • National Guinea Worm Eradication Program 910 • Universal Immunization Program 910 • National Poliomyelitis Eradication Program 911 • Polio Eradication: A Land Mark Achievement for India 917 • Global Polio Eradication Initiative 919 • Revised National Tuberculosis Control Program 921 • National Acute Respiratory Infections Control Program 923 • National Diarrheal Diseases Control Program 923 • National AIDS Control Program 924 • ‘3 by 5’ Initiative 930 • National Program on Prevention and Control of Viral Hepatitis 930 • National Program for the Control of Blindness 931 • National Program for Prevention and Control of Deafness 933 • National Cancer Control Program 935 • National Program for Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke 935 • National Mental Health Program 937 • District Mental Health Program 937 • National Iodine Deficiency Disorders Control Program 938 • National Program for Control and Treatment of Occupational Diseases 939 • National Program on Prevention and Control of Fluorosis 940 • National Vitamin ‘A’ Prophylaxis Program 942 • National Nutritional Anemia Control Program 943 • National Special Nutrition Program 943 • National Balwadi Nutrition Program 943 • National Mid-day School Meal Program 943 • National Integrated Child Development Services Scheme 943 • National Program for Health Care of the Elderly 943 • National Tobacco Control Program 944 • National Family Welfare Program 948 • National Family Planning Indemnity Scheme 949 • National Reproductive and Child Health Program 950 • Reproductive and Child Health Program-II 955 • Components of Reproductive and Child Health Program-II 955 • All India Hospital Postpartum Program 958 • National Water Supply and Sanitation Program 958 • Minimum Needs Program 959 • Twenty Point Program 960
Section 8: Allied Subjects
45. Emerging and Re-emerging Infectious Diseases 965Emerging Infectious Diseases 965 • Re-emerging Infectious Diseases 969 • Control of Emerging and Re-emerging Diseases 970
46. Disaster Management 971Impact 971 • Classification of Disasters 971 • Disaster Management Cycle 973
47. Integrated Disease Surveillance Project: 2004–2009 976Surveillance 976
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48. Bioterrorism 979Historical Background 979 • Evolution of Chemical and Biological Weapons 979
49. Global Warming 982History of Global Warming 982 • Hazards of Global Warming 982 • Who is the Worst Polluter? 983 • Kyoto Protocol 984 • Action Needs to be Taken Now 984 • Containment Measures 984
50. Integrated Management of Childhood Illness 985Objectives 985 • Components 985 • Principles 986 • Assess and Classify the Sick Child 988 • Identification of the Treatment 995 • Counsel the Mother 997
51. Telemedicine in Public Health 1000Aim of Telemedicine 1000 • Utility of Telemedicine 1001 • Types of Technology 1001 • Telemedicine in India 1002 • Current Efforts in India 1004
52. Tobacco and Health 1006Prevalence of Smoking 1006 • Public Health Importance 1006 • Types of Tobacco 1007 • Composition of Smoke 1007 • Health Hazards of Tobacco 1008 • Health Benefits of Smoking 1009 • National Tobacco Control Program (NTCP) 1010
53. Public Health Acts 1011The Consumer Protection Act, 1986 1012 • Registration of Births and Deaths Act, 1969 1012 • Pre-conception and Prenatal Diagnostic Techniques (PC PNDT) Act, 1994 1013
Annexure 1015Some Stalwarts and their Contribution to Community Medicine 1015 • Edward Jenner (1749–1823) 1016 • Sir Edwin Chadwick (1800–1890) 1016 • Louis Pasteur (1822–1895) 1016 • Joseph Lister (1827–1912) 1016 • Robert Koch (1843–1910) 1017 • Ronald Ross (1857–1932) 1017 • Calendar of Important Dates and Events 1017 • List of World Breastfeeding Week Themes Since 1992 1018 • List of World Health Day Themes 1018 • Goals to be Achieved by 2000–2015 1019 • Milestones in Vaccination 1020
Index 1021
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‘Geriatrics’ is the science that deals with the study of diseases and their treatment peculiar to old age (clinical gerontology, i.e. the study of pathological aspects of old age). ‘Gerontology’ is the study of physiological and psychological changes, which are incident to old age (i.e. study of aging process).
There is no standard definition of old age. Aging is a normal, inevitable, biological phenomenon and it is not known when the old age begins. United Nations (1980) considers 60 years as the age of transition to the elderly age group. In India, people aged 60 years and above are treated as old. Old age is often classified into ‘early old age’ up to 75 years (elderly) and ‘late old age’ (very elderly) for those above 75 years. In developed countries, people at 65 years and beyond are treated as ‘elderly.’
Aging is a physiological process that starts from birth, continues throughout life and ends with death. The process of aging of an individual is assessed by comparing biological age with chronological age. • If biological age corresponds to chronological age, the
aging process is ‘normal’. • Ifbiologicalagelagsbehindchronologicalage,theaging
is ‘delayed or retarded’. • Ifbiologicalagehasadvancedaheadofchronologicalage,
the aging is described as ‘precocious or premature.’While aging stands merely for growing old, ‘sene-
scence’ means deterioration in the vitality or lowering of the biological efficiency or feebleness of the body and mind, associated with the process of aging, such as decline in sexual prowess, diminution in the endocrine activity, loss of elasticity of blood vessels and rise in blood pressure. These physiological changes associated with aging are often referred to as ‘Eugeric’ changes, which are the outcome of
interaction between evolution or growth and involution or atrophy, which start from womb to tomb. In early years evolution dominates involution; balance each other during middle age and in the old age involution dominates evolution, resulting in senescence. Eugeric changes are functional as well as structural, manifesting at all levels and affect the cells, the tissues, the organs and even the configuration of the body.
POPULATION OF THE AGED
As the life expectancy is rising, the population of the aged people is also increasing steadily. The world population prospectus released by United Nations in 1998 reveals that the population of the aged at global level is 9 percent (6.7% in less developed countries and 15% in developed countries). Though the proportion of elderly population is more in developed countries, majority of the old people live in developing countries. In absolute numbers, out of about 530 million people, above 60 years, living in the world, about 355 (61.2%) million people live in developing countries. By the year 2020, the world population of old people would be about 1,000 million, of which about 700 million (70%) would be living in developing countries resulting in increasing the burden of diseases associated with old age.
In India, the proportion of aged population was 5 percent in 1971; 6 percent in 1981; 6.7 percent in 1991 and 7.7 percent during 2001. It is likely to increase beyond 8 percent in the next decade.
Japan is the most elderly country in the whole world. The average lifespan of Japanese is 82 years.
C H A P T E R 29Preventive Geriatrics
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THEORIES OF AGING PROCESS
Somatic Mutation TheoryAccording to this, there is progressive accumulation of mutations in the DNA leading to incapacitation of the cells.
Autoimmune Theory According to this, as the age advances, there is faltering in the process of protein synthesis, resulting in the production of a new protein, which is not accepted by the body resulting in the production of antibodies against it, which is the basis of senescence.
Hayflick’s TheoryAccording to Hayflick, old age sets in, when the body cells exhaust the capacity of undergoing multiplication.
HEALTH PROBLEMS OF THE AGED
These are grouped into physiological, psychological, social and pathological problems.
Physiological ProblemsThese are normally occurring and are due to aging process (i.e. eugeric changes), resulting in disabilities. These are senile cataract, glaucoma, nerve deafness, bony senses affecting mobility, emphysema, failure of special changes, changes in physical outlook (wrinkles of the skin) and mental outlook.
Psychological Problems• Mental changes: Loss of memory (senile dementia)
associated with impaired comprehension and impaired intellectual performance.
• Decline insexualperformanceresulting inphysicalandemotional disturbances.
• Isolation: Death of the kith and kin, lack of care by the younger generation, social maladjustment and such other leads to isolation.
• Depression: The symptoms of depression are lack of interest in the activities, sadness, unexplained crying spells, irritability, loss of memory, inability to concentrate, confusion, disorientation, thoughts of death or suicide, change of appetite and sleep pattern, persistent fatigue,
lethargy, aches, etc. The factors predisposing for depression are isolation, poverty, presence of disease/diseases, suffering, emotional disturbances, lack of happiness, etc. The depression may even lead to suicide.
Social ProblemsThese are poverty (due to retirement, loss of income, more expenditure due to ill health, etc.), isolation (due to death of family members), maladjustment with younger generation, unhealthy lifestyles like smoking, alcoholism etc. Idleness and boredom are other social problems.
Pathological Problems• Diseases of the heart and blood vessels: Such as
hypertension, atherosclerosis, myocardial infarction, cerebrovascular diseases like stroke. There are two types of strokes: (a) Ischemic stroke is due to sudden block of blood supply to the brain (as in thromboembolic phenomenon) leading to paralysis of one side of the body. This occurs in 85 percent of patients. (b) Hemorrhagic stroke is due to sudden rupture of artery within the brain leading to brain hemorrhagic and paralysis of one half of the body.
• Cancer,diabetesmellitus,obesity• Diseasesoftheeyes: These are cataract, age related macular
degeneration (AMD), loss of vision due to refractive errors, retinopathy, etc.
• Diseases of bones and joints: These are spondylosis, myositis, fibrositis, osteoarthritis, osteoporosis, gout, rheumatoid arthritis, fractures, etc.
Osteoarthritis is a chronic, irreversible degenerative condition, due to breakdown of cartilage in joints, causing the affected bones to rub against each other leading to permanent damage.
Osteoporosis is a silent disease in which the bones become fragile. If left untreated, it progresses painlessly until a bone breaks resulting in fracture, typically in hip, spine and wrist. They are extremely painful and take long time to heal.
Gout is characterized by accumulation of excess of uric acid in the body, which then accumulates in certain joints, usually the big toe, causing sudden attack of pain, warmth, swelling, redness and tenderness.
Rheumatoid arthritis is the inflammation of usually the peripheral joints such as hands, fingers and toes, resulting in functional disability, significant pain and joint destruction, leading to deformity and premature mortality.
• Diseasesof therespiratorysystem: Common diseases are chronic bronchitis, bronchial asthma, emphysema, etc.
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• Diseases of the genitourinary system: These are enlargement of prostate, incontinence of urine, dysuria, nocturia, urinary infection, fecal incontinence, etc.
• Diseasesofthenervoussystem: Common are Alzheimer’s disease and Parkinson’s disease.
Alzheimer’s disease is a slow, progressive degenerative disease of the brain, leading to mental deterioration beginning from that part of the brain which controls memory. As it spreads to other parts of the brain, it affects greater number of intellectual, emotional and behavioral abilities. There is no known cause. Older the age, greater the risk of developing the disease. After 60, the risk is one in 20, but after 80, it is one in 5.
CARE OF THE AGED
Ideally, this should begin much early right from childhood. The promotive measures undertaken during childhood and adolescence constitutes ‘pregeriatric care’ and when continued during old age, the objective would be to ‘add life to years’ and not just years to life (i.e. to reduce disability and improve the quality of life).
Primary Prevention
Health PromotionThese are the measures to remain healthy in old age. These are: • Controlthebloodpressure,weightanddiabetesifany.• Avoid smoking and limit alcohol intake to lead healthy
life-style.• Regular,moderate,physical exercise,whichunlocks the
stem-cells of the muscles and rejuvenate old muscles. Endurance exercise improves the levels of spontaneous locomotion. Exercise also wards off dementia and mental decline.
• Avoidanceofdrugabuseandself-medication.• Well balanceddiet, low in saturated fats, refined sugars
and fast foods. Add calcium rich diet, fruits vegetables and greens. Tomatoes can save from high cholesterol and hypertension because of a pigment, lycopene, which has antioxidant property. It is also found in watermelon, guava and papaya.
• Cultivation of interest in reading, writing, listening tomusic, doing puzzles, playing chess games, hobbies, social work, pet keeping or such other diversional activities, which can keep them busy and give exercise to the brain.
• Avoidlonelinessbyengaginginrecreationalactivities.• Drinkenoughwatertokeepawayfromchancesofrenal
stones and urinary problems.
• Periodical screening for blood pressure, vision andhearing.
• Planforfuturefinancial,housinganddiseasesecurity.• They should build up a large circle of friends and well
wishers by selfless behavior, kindness and social service, which will prove useful to them.
• Yoga exercises and meditation goes a long way inpromoting the health.
Specific ProtectionAll aged people must be immunized against diseases such as influenza, pneumococcal pneumonia, tetanus and hepatitis B. They must also be immunized selectively against, hepatitis A, meningococcal meningitis, Japanese encephalitis and rabies.
Secondary PreventionEarly Diagnosis and TreatmentSince most of the diseases of the old age are predictable, they can be identified by periodic screening for health and start treatment. Timely detection and intervention can preserve the quality of life.
The elderly people are educated about the ‘danger signals’ of cancer.
Women are educated regarding self-palpation of breasts for presence of lump.
Exfoliative cytology of vaginal/cervical smear (Pap smear) examination of all those women, who have attained menopause and complain of vaginal bleeding to rule out cancer cervix.
Tertiary Prevention
Disability LimitationThis consists of giving an intensive treatment in the hospital for those who come in the advanced stage of the disease.
RehabilitationThis consists of training and retraining the patients with the remaining capacity so that they can build up self-confidence to take care of themselves. The various measures of rehabilitation are: • Cataractsurgery,provisionofspectacles• Hearingaids,artificiallimbs,earmoulds,prostheses,etc.• Physiotherapy, vocational therapy, psychological and
social therapy depending upon their functional capacities.• Deaddiction counseling for those who have become
addicts.
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Improvement in the quality of life is done by the following measures in the community:• Organization of cultural programs like harikathas,
bhajans, etc. • Arrangementofthepicnicsandtours.• Establishmentofoldageclubs,where themembersare
given training in yoga, meditation, philosophy, etc.• Establishmentofoldagehomesfor thedestituteelderly
persons.• Thiscouldbedoneonthebasisofsomepayments.
OLD AGE SOCIAL AND INCOME SECURITY
IntroductionAging is a development issue. It is a matter of time that everyone gets older. Healthy older persons are a resource for all. They make major contributions to the society. Older people play a critical role through volunteer work, promoting knowledge, helping the community and families by sharing their experiences towards building a strong nation. The development can only be ensured if older persons enjoy healthy, happy and contented life.
Since the joint family and traditional support structure of the family is breaking down, the children are unable to take care of their parents, millions of elderly face destitution. They are trapped in misery through a combination of low income and poor health.
Background• Thepopulationofaged60andaboveisincreasing(Itwas
about 6.7% in 1991 and will be about 8.9% in 2016 and 13.3% in 2026).
• Todaytheyareexpectedlivebeyond75yearsofage.SoanIndian worker must have adequate resources to support himself for approximately 15 years after his retirement.
• The economic security provided by the Governmentthrough pension provision has been a serious drain on Government finances. Most individuals are myopic during their earning lifetimes
with regard to saving for their old age and may thus be reluctant to save adequately for their old age income security in a purely voluntary environment.
Government of India realizes that poverty alleviation programs directed at the aged alone cannot provide a complete solution to the problem. In this background, the project Old age social and income security (OASIS) took birth during 1999 under the Ministry of Social Justice and
Empowerment. The basic mandate of the project is to make concrete recommendations for action, which the Government of India can take today, so that every citizen can genuinely build up a stock of wealth through his/her working life, which would serve as a shield against poverty in old age.
Since there is already existence of Provident Fund system, the challenge is therefore not to ask the workers to save more but to convert high savings rate into old age security. So the project recommends the following:• Limitearlywithdrawals• Deploy superior financial portfolio management
information system so as to obtain higher rate of returns• Expandthecoverageofexistingprovidentfundsystemas
to reach more workers • Improvecustomerserviceoftheexistingprovidentfund
system. Thus, OASIS is a project of national importance. The
Providend Fund (PF) Act was introduced way back in 1925 itself. There is also Public Providend Fund (PPF) scheme for self-employed. This is confined to large cities only.
The OASIS project has two phases. First phase covers the existing mechanisms for social security—PF, PPF and pension scheme, which should be further improved. The second phase covers other issues including a new voluntary pension system, individual choice of diverse funds and fund managers, regulatory authority for the pension fund industry and need for a Redistributive pillar, i.e.:• Noncontributory Government pensions (Central and
State Government plans, Railway, Armed forces, Post and Telegraph).
• OccupationalandPrivatePensionPlans.• Contributorypension,provision foruncoveredworkers,
farmers, etc.• Strengtheningtheexistingsocialwelfareschemes.
Social Security Net
Indira Gandhi National Old Age Pension SchemeObjective: The objective is to disburse pension to the destitute
old age persons.Assistanceprovided: `400/- per month.• Beneficiary: Beyond 65 years of age, belonging to BPL
(below poverty line) and 60 years and above for persons affected by leprosy, blindness, insanity, paralysis and loss of limb.
• Otherbenefits: One free dhoti for male and one free saree for female, supplied twice a year for Deepawali and Pongal festivals.
• All pensioners are supplied daily with free nutritious meal. 2 kgs of rice per month to those who are taking nutritious
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meal and 4 kgs of rice per month for those who are not taking nutritious meal, are supplied at free of cost.
• Procedurestoapply: Applied in a prescribed form obtained from Taluk office or in a plain paper duly filled up and sent to Tahsildar/Special Tahsildar (Social Security Scheme).Grievances to be reported to Revenue Divisional Officer/
District Collector.
Annapurna Scheme• Objective: The objective is to ensure food security to the
old age pensioners.• Assistanceprovided: It is 10 kgs of rice or wheat per month,
supplied free of cost to the destitute senior most citizens among National Old Age Pension Scheme beneficiaries. Separate cards labeled, ‘Annapurna’ are issued to the
beneficiaries, collected from District Collector.This new scheme is yet to be implemented.
HELPAGE INDIA
It is a secular, nonprofit, largest voluntary organization, registered under the ‘Societies Registration Act of 1860’. It was set up in 1978 and since then it has been working for the cause and care of disadvantaged old people. It has been raising resources to protect the rights of India’s elderly people and provide relief to them through various interventions. • It brings about various policies that is beneficial to the
elderly• It promotes better understanding of aging issues• It creates awareness about rights of the elderly• It helps them to play an active role in the society• It supports the following programs for them:
– Free cataract operations– Mobile medical care units– Income generation and micro-credit– Old age home, day care centers, etc.– Cancer and Alzheimer’s projects.
NATIONAL POLICY ON OLDER PERSONS
National Policy on Older Persons (NPOP) was formed in January 1999, under the Ministry of Social Justice and Empowerment. It seeks to assure older persons, above 60 years of age, that their concerns are national concerns and they will not live unprotected, ignored and marginalized. The goal of the National Policy is the well being of older persons. It aims to strengthen their legitimate place in society and
help older persons to live their last phase of life with purpose, dignity and peace.
The NPOP visualizes that the State will extend support for financial security, health care, nutrition, shelter, provision of appropriate concessions, rebate, discounts, etc. for all senior citizens and special attention to protect and strengthen their legal rights so as to safeguard their life and property. This policy is operated by National Council for Older Persons.
The policy provides broad framework for collaboration and cooperation between Governmental and Nongovernmental agencies.
BENEFITS GIVEN TO SENIOR CITIZENS OF INDIA
1. NationalPolicyonOlderPersons: Explained already. 2. MinistryofRuralDevelopment: Under National Old Age
Pension Scheme, Central Assistance of `75/- per month is granted to destitute older persons above 65 years.
Under Annapurna Scheme, free food grains (wheat or rice) up to 10 kg per month are provided to destitute older persons above 65 years of age who are eligible for old age pension but not receiving it.
3. MinistryofFinance: Union Budget 2011–12. Section 88 of the Finance Act 1992 provides income tax
rebate up to `15,000/- or actual tax whichever is less to senior citizens, who have attained the age of 65 years at any time during the relevant previous year.
Senior citizens are excluded from ‘One by Six’ scheme for filling the Income Tax Return underprovison Section 139(1). The deduction in respect of Medical Insurance premium is up to `15,000/- under section 80 D, w.e.f. 2000–01.
Reserve Bank of India has permitted 0.5 percent higher rate of interest on fixed deposits in the bans.
4. MinistryofHealthandFamilyWelfare: Separate queues are provided to senior citizens in the hospitals for registration and clinical examinations.
5. MinistryofRailways: Railway budget 2010–11. Concessions to senior citizens are hiked from 30 to 40
percent for men above 60 years and for women above 58 years, for booking/cancellation of railway tickets.
6. MinistryofCivilAviation:Fifty percent discount on basic fare for all domestic flights in Economy Class for above 65 years of age and in Sahara India Airlines for above 62 years of age, for both men and women.
7. MinistryofRoadTransportandHighways: The benefit is given after 65 years of age for both men and women.
8. Department of Post Office: A new scheme called ‘Senior Citizen Saving Scheme’ has been notified w.e.f.
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August 2, 2004. The maturity period of deposit will be five years, extendable by another three years, in designated post offices throughout the country.
Under this scheme, people above 60 years are eligible to invest minimum of `1000/- and in multiples of `1000/- subject to a maximum of `15 lakhs, with single or joint account with spouse only.
Those who have taken voluntary retirement at 55 years of age, are also eligible, subject to specified conditions. The deposit will carry an interest of 9 percent per annum, taxable. Premature withdrawl after one year is allowed subject to some conditions. The investment is nontransferable and nontradable. However, nomination
facility will be available. Non-Resident Indians and Hindu undevided families are not eligible to invest in this scheme.
BIBLIOGRAPHY 1. http://www.seniorindian.com/OASIS_htm. 2. http://www/tn.gov.in/schemes/swnmp/socialsecurty-net.pdf. 3. http://www/helpageindia.org/aboutus.php. 4. ICMR. Health Care of the Elderly. Bulletin 1996;26(5). 5. LalS.AddingLifetoYears.IndJLofComMed1999;24(4):143-6. 6. Voluntary Association of Health India. Health Problems of
Specialized Groups. Chapter 14, 1997.
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