Epidemiology Exercises
- 1. 22.An anganwadi school teacher reported 5 cases of maculopapular rash. The children had cold, cough, and it started with fever. What is the health problem and how do you manage these cases? What are the containment and preventive measures you take?
- 3. MANAGEMENT DIAGNOSIS TREATMENT PREVENTION AND CONTROL ELIMINATION VACCINATION HEALTH EDUCATION CASES CONTACTS IMMUNISATION IMMUNOGLOBULINS
- 4. TREATMENT OF MEASLES CASE Require NURSING CARE rather than DRUG THERAPY OBJECTIVES Physical, Emotional, Therapeutic COMFORT Prevention of COMPLICATIONS ELEMENTS OF NURSING CARE •ISOLATION for 7-10 days after rash •DISINFECTION of infected articles •DIETARY care •ORAL HYGEINE •SKIN care ( No SOAP – Eruptive phase ) •RESP care (GENTLE BLOWING of Nose , HUMIDIFICATION) •EYE care •Prevention of DECUBITUS ULCERS and CONTRACTURES
- 5. IMMUNISATION HEALTH EDUCATION PASSIVE IMMUNISATION By immunoglobulin ACTIVE IMMUNISATION Single vaccine Combined vaccine M.M.R VACCINE-1971 M.M.R.VACCINE-2005 MEASLES VACCINE-1963 •Killed vac •Live vac PREVENTION OF MEASLES
- 6. CASE IS CONTACT SUSCEPTIBLE? YES IS CONTACT IMMUNOCOMPROMISED NO YES NO ACTION REQUIRED OFFER IMMUNOGLOBULIN AGE 6-9 months AGE >9 months CONTACT IN 7 DAYS CONTACT BET 3-7 DAYS CONTACT IN 3 DAYS IS CONTACT IMMUNOCOMPROMISED YES VACCINE IDENTIFY ALL CONTACTS NO NO ASSESMENT AND MANAGEMENT OF CONTACTS
- 7. 23. On March 20th 2009, an outbreak of A/H1N1 influenza occurred in Mexico. By 29th April neighbouring nine countries have reported 148 confirmed cases including seven deaths. WHO has declared it as pandemic imminent (phase 5). Outline the measures to be taken in the country.
- 8. • Solution: • India is an influenza A/H1N1 receptive area. Population of the country is susceptible to A/H1N1 virus • Infection can enter through clinical/ subclinical travelers. International health regulations of WHO are adopted to restrict the entry and spread of infection. Strict aerial and marine traffic regulation is undertaken.
- 9. • Regulation for travelers • Restriction of travel in close borders • Examination of all travelers from affected countries • Quarantine for longest incubation period for such travelers • If any infected case is noticed, all the co-passengers and their contacts should be traced and examined for the disease.
- 10. • Outbreak response and pandemic preparedness plans • Identification of hospitals for treatment • Reserving beds for isolation of patient in government, private hospitals • Utilization of doctors specialized in treating chest infections • Arrangements for sufficient drugs, equipment, manpower, transport, communication etc • Notification of disease • Request for national and international assistance and support • Containment for affected country. Alert phase to other countries • Detaining high-risk population.
- 11. • Early detection and treatment • Screening of all travelers at airport • Co- travelers of the suspects are identified and screened. • Defining the disease • Individuals with positive test for influenza A/H1N1 • Clinical compatible illness or having died with unexplained acute respiratory illness linked to be probable or confirmed case. • Clinical description • Acute febrile (> 38 degree centigrade) respiratory illness, ranging from influenza like illness to pneumonia.
- 12. • Laboratory confirmation • Sample has to be flown by air to National Institute of Virology (NIV), Pune or National Institute of Communicable Diseases (NICD), Delhi. • Confirmation tests: • Real time RT-PCR • Viral culture • Four-fold increase in swine influenza (A/H1N1) virus neutralizing antibodies • Case management • Isolation • Drug (treatment): oseltamivir- recommended only for confirmed cases • Every case of influenza or pneumonia is rigorously isolated • Rapid containment measures are adopted • Reviewing and revising pandemic plans by periodic comprehensive assessment
- 13. • Assessment of situation • Rapid but detailed investigation by epidemiological experts • Assessment of disease: virological , epidemiological, clinical • Geographic analysis: Trend, spread, intensity, impact • Health education, awareness and advice • Given throughout the country through mass media • Reassurance and relieving anxiety is essential as people will be panic during the pandemic • Preventing exposure to pigs and infected humans • Do not shake hands, hug or kiss socially • Do not practice indiscriminate spitting, coughing, sneezing, hawking in public places
- 14. • 24. A 40 year old female primary school teacher was diagnosed with pulmonary tuberculosis. Sputum was positive for AFB. How do you manage the case? What health education is required? How do you prevent the infection to contacts?
- 15. • Solution: Baseline data collection Confirmation of diagnosis. • Clinical history • Sputum positivity • School teacher is an open case , she is spreading the infection to school children, to co-workers in the school, family members, hence highest priority should be given for early diagnosis and treatment.
- 16. • Treatment: • Sputum examination report is recorded • Teacher is registered and treated under RNTCP. • Direct observed therapy short-term (DOTS) is given • According to the DOTS, teacher is stratified under category I for treatment schedule. • Advice to patient: • Take drugs regularly and completely. • Cover the mouth with cloth while coughing, sneezing • Take good food, do regular walking/exercise • Avoid indiscriminate spitting.
- 17. • Undergo periodic follow up. • Stop smoking. • Hygienic disposal of sputum • Screening of school children: • Examination of BCG scar, clinical symptomps-fever, cough, weight loss. • Suspected child subjected for three sputum examination Chest X rays Gastric lavage and other procedure - Students found positive, should be promptly treated. - Health education is given to children along with their parents.
- 18. • Family memebers: • Husband and infant is screened for tuberculosis. If positive, prompt treatment is given. • INH prophylaxis to baby , If indicated. BCG vaccination is given to the baby if not given earlier.
- 19. 25. A 35 year old anganwadi teacher is having three hypo pigmented anaesthetic patches on her right arm. How will you manage this case and suggest the remedial measures to be taken?
- 20. • Laboratory investigations • Skin smear: • Site • First skin lesion • Second skin lesion • Third skin lesion • Fourth skin lesion • Left ear lobe • Right ear lobe • Nasal smear • Bacteriological index (BI) = total positives/ total number(7) of sites examined • *Negative No bacilli in 100 fields • One plus(+) One or less than one bacilli in each field • Two plus(++) Bacilli found in all fields • Three plus(+++) Many bacilli found in all fields • Classification by BI >2 <2
- 21. • Diagnosis of leprosy criteria • Hypo pigmented patches • Loss of sensation • Thickened/ tender nerves • Presence of bacteria
- 22. • Treatment • Patient is registered and treated under the National Leprosy Eradication Programme (NLEP) • Objectives of treatment (MDT) • To interrupt transmission. • To cure the case. • To prevent drug resistance.
- 23. Treatment schedule Type of leprosy Duration of treatment( month) Rifampicin- 600 mg Dapsone- 100mg clofazemine MBL 12 Once a month supervised Daily self 300 mg once a month supervised, 50 mg daily self PBL 6 Once a month supervised Daily self Nil
- 24. • Follow up surveillance • After completion of treatment • Paucibacillary once a year for 2 year • Multibacillary once in a year for 5 year • Patient who does not show evidence of relapse( clinical and bacteriological) during the period of surveillance is released from treatment/ control. • For close contacts • Periodic examination • Chemoprophylaxis: Dapsone- 4 mg/kg weight per week for 3 year • Immunoprophylaxis: BCG ( as relevant )
- 25. • Advice • Patient: Take drugs regularly and completely • Go for periodic check up • Hygienic disposal of nasal secretion • To use micro cellular foot wear • Family: Accept the patient, do not discriminate • Motivate for treatment • Community: Health education about cause, cure and availability of services Removal of the stigma attached to leprosy Improvements in living standards Creating awareness regarding NLEP
- 26. • Community level activities ( education ) • Leprosy is not due to sin, it is caused by bacteria • Leprosy can be completely cured • Early detection of cases by -- Mass surveys -- Contact survey • School children examination • Voluntary referral • Examination of slum population • Registration of cases for treatment • Motivation of affected for early diagnosis and treatment • Social support • Assistance- travelling, food etc • Job replacement • Vocational training • Abolishing social evils
- 27. • 26. A 15 year old boy was bitten by a stray dog on his back and right arm, with a lacerated wound of 2.5 cm * 0.5 cm. What measures are to be taken?
- 28. • Solution: • Base line details collection • Wound details: • Site of wound, distance from the brain • Type of bite- superficial, deep or mere lick • Number of bites • Bite- bare skin or interposing cloth
- 29. Classification of bite class Type of contact management I Mouth contact , feeding, lick on skin None II Nibbling of uncovered skin having minor scratch or abrasions without bleeding Start rabies vaccination III Transdermal bites, lick on broken bleeding skin Rabies immunoglobulin +active vaccination
- 30. • Wound management: • Wound treatment must be done immediately as early as possible • Flushing and washing the wound and adjoining area with plenty of soap and water, under running tap water for at least 5 minutes. • Virucidial agents like povidine iodine, or antiseptics like Savlon or Dettol is to be applied to the cleaned wound • Suturing and dressing are generally avoided or postponed.
- 31. POST EXPOSURE PROPHYLAXIS • Tetanus toxoid • Systemic antibiotics • Rabies prophylaxis • As per the WHO recommendations, the new generation vaccine should administered to class II and class III exposures • Along with vaccine, RIG is also given to class III exposure.
- 32. PASSIVE IMMUNIZASION • Immunoglobulin schedule: Rabies immunoglobulin Preparation concentration per ml Dose /kg body weight Maximal dose HRIG 150 IU 20 IU 1500 IU ERIG 300 IU 0.134 ml 10 ml Major part of the dose is administered around the wound. Rest is injected intramuscularly to the gluteal region.
- 33. Active immunization • Intra Muscular Schedule • Dose : HDCV, PCEV, PDEV & PVCV – 0.5 ml & 1 ml • Site : Deltoid • Route : Intra Muscular • Schedule: Day O, 3, 7, 14, 28,90. • Note: Estimate Rabies neutralizing antibody titers in the serum, if titers are < 0.5 IU / ml , give booster. • Protective value ( 0.5 IU/ml ) is attained by 10 to 14 days, which lasts for 3 months.
- 34. Advice to patient/ attendant • Take complete treatment timely. • There is no contraindications for Rabies vaccine • Avoid steroid, chloroquine, and immunosuppressive drugs. • Avoid physical and mental strain, late nights and alcohol. • Report immediately in case of fever, pain, stiffness in neck and limbs. • People are educated to seek treatment for all dog bites. • There is no secondary prevention, except ensuring a comfortable death.
- 35. • 27. In a village, an untrained dai conducted delivery on a primi gravida. The neonate which was normal up to a week could not take feeds, developed convulsions and spasm of limbs. Discuss the health problem and enumerate the preventive measures
- 36. • This is a case of neonatal tetanus. The child is immediately admitted to district hospital/referral center for treatment.
- 37. Management • Passive and active immunization: • (Best given within 6 hours of birth) • Passive: • Tetanus hyper immunoglobulin (TIG) 250 IU to 500 IU is given by IM route • Tetanus anti toxin neutralizes the circulating toxins but not the toxin already fixed to nerve roots. • Passive protection is up to 30 days only. • If human TIG is not available anti tetanus serum (ATS) given subcutaneously 1500 IU after test dose. • It gives passive protection for 7 days.
- 38. • Active: • Along with human hyper immunoglobulin. • First dose of 0.5 ml tetanus toxoid is given to another site. • 6 weeks later, second dose of tetanus toxoid is given. • One year later, third dose is given. Regular vaccination is continued • General treatment and supportive measures. • The child is nursed in well-lighted, quite room. • IM injections and handling of child is minimized as it will provocate spasm • Maintenance of airway - sucking secretions, oxygen is given, if necessary.
- 39. • Nutrition (Oral feeding is stopped) intravenous / nasogastric tube feeding is given. • Fluid, electrolyte and temperature is maintained. • Control of spasm – Diazepam IV 0.5 to 1 mg/kg every 3 to 4 hour. • Antibiotic – penicillin • Tracheostomy, assisted ventilation- if indicated • Prevention • Utilization of health services • Clean delivery practices – institutional • Trained attendants • Providing home delivery kit • Educating pregnant women about clean delivery
- 40. • Clean hands • Clean blade • Clean surface • Clean tie • Clean cord care • No application to cord stump • Tetanus toxoid to pregnant women • First dose: As early as possible • At least three weeks before delivery ( no pregnant should be deprived of at least 1 dose even if she is seen late in pregnancy) • Tetanus toxoid two doses to all women of child bearing age at 1 month interval.
- 41. • 28. A 25 year old man came to the casualty, with unclean deep wounds on both the legs with considerable tissue damage sustained on the previous day. The person has taken TT vaccine 12 years back. How do you manage the case?
- 42. Wound management • Proper cleaning of wound • Suturing if necessary • Sterile dressing • TT prophylaxis
- 43. • Antibiotics: • Antibiotics should be given as soon as possible after an injury, before a lethal dose of toxin is produced i.e., with in 6hrs after injury. • A single IM injection of long acting penicillin e.g.: Benzathine penicillin will provide a sustained concentration of the drug for 3 to 4 weeks, which sufficient to kill any vegetative forms of tetanus bacilli that may emerge from spores. • For patients sensitive to penicillin, erythromycin is given.
- 44. Prevention: 1. Active immunization: Tetanus is best prevented by active immunization with tetanus toxoid. Toxoid is the one which is inactive form of toxin with no toxigenicity but retained antigenicity. It stimulates the production of protective anti toxin . Two types: 1. Combined vaccine – DPT. 2. Monovalent vaccines a. plain or formal toxoid. b. Adsorbed toxiod (PTAP , APT)
- 45. a. Combined vaccine: Infants are immunized against tetanus in combination with Diphtheria, pertussis as DPT Vaccine. D – Diphtheria toxiod. P – killed B.pertussis. T – Tetanus toxiod. According to the national immunization schedule, the primary course of immunization consists of 3 doses of DPT.
- 46. 6 weeks - PENTAVALANT 1 10weeks - PENTAVALANT 2 14weeks - PENTAVALANT 3 Booster at 18 months - DPT booster 1 At 5 years - DT Third Booster - TT b. Monovalent Vaccines: Purified Tetanus toxoid has a longer lasting immune response than plain toxiod. Primary course of immunization consists of three doses.
- 47. Persons Seven Years of Age or Older Who Have Not Been Immunized • Immunization requires at least three doses of Td. • 1st dose should be administered on the First visit • 2nd dose 4 – 8 weeks after the first dose of Td and 3rd dose after 6 months of the second Td. • A booster dose of Td should be repeated every 10 years throughout life
- 48. Passive Immunization Temporary protection against tetanus can be provided by injection of 1.Human tetanus hyperimmunoglobulin 2. Antitetanus Serum. TIG: dose for all ages is 250 – 500 IU. It gives a longer passive protection up to 30 days or more compared with 7 – 10 days for horse ATS.
- 49. Antitetanus Serum: if human antitoxin is not available equine antitoxin should be used. Standard dose is 1500 IU injected SC after sensitivity testing. As equine anti toxin is foreign protein, it is rapidly excreted from the body and there may be very little antibody at end of 2 weeks. ATS gives protection for about 7 – 10 days.
- 50. • 29. During the year 2016, 227 two wheeler accidents occurred at a particular junction in a metropolitan city. Most of the accidents involved young males in 18 – 25 yrs group. Discuss the health problem and its preventive aspects
- 51. Factors influencing on road traffic accidents • Place of accidents: • Road conditions • Procession /obstruction in road • Road defects, very narrow roads • Cyclists , children and animal movements on road • Excess of traffic, bad illumination • Curves, lack of speed brakers • Person met with accident: • Age , sex • Defective and delay in decision • Excess speed, poor driving standards • Ill-health, defect in vision and hearing • Risk behavior: fantasy, impulsive, aggressiveness, emotional tentions. • Poor sychological status
- 52. • Lack of sleep, fatigue • Influence of medicine, drug, alcohol • Sudden ill health like epilepsy, MI • TIME OF ACCIDENT: • Month, week, day, time. • ENVIRONMENT: • Fog , rain, natural calamities and sudden damage of roads • Excess heat or cold • Vehicle involved in accidents: • Condition of vehicle • Safety device ( helmet, seat belt) • Social factors: • Trend of license issuing • Supervision by parents • Traffic control/signals • Enforcement of law
- 53. Measurment of the problem Number of deaths due to accident • Proportion mortality= * 100 Total deaths Number of two wheeler accident Accident rate per 1000 two wheelers= Total number of two wheelers *100
- 54. Prevention • General measures: • Accident prevention education • Improvement of roads • Application of all road safety measures, improvement of road conditions • Proper control of traffic • Supervision by the elder • Engineering measure to make safe vehicles • Survey and research on road accidents • Notification • Celebrating awareness campaign like road safety week.
- 55. • Medical measures: • Providing medical care emergency transport services(108 vehicles) • Periodic counseling and behavioral modification • Training medical and paramedical staff in first aid resuscitation and trauma care. • Legal measures: 1. Licensing regulation 2. Limiting the speed 3. Separation of fast/slow tracks 4. Use of protective device like helmet and seat belt 5. Timely inspection of vehicles for road fitness 6. Prohibition of driving after alcohol 7. Prohibiting animals in road
- 56. • 30. A 45 year old male who is a clerk by occupation came to the PHC with complaints of tingling and numbness in limbs and foot ulcer. Random blood sugar level was 345 mg/dl and BMI – 31kg/m 2. How will you manage this case? What is the health advice given to the patient?
- 57. • From case history , it is understood that it’s a case of uncontrolled diabetes and Obese class I
- 58. Prevention & Care 1.Primary prevention a)Population strategy b)High risk strategy 2.Secondary prevention
- 59. Prevention & Care 1.Primary prevention Population strategy : 1)Healthy dietary habits– less sweets, less salt, adequate protein, high intake of dietary fibre 2)Physical exercise 3)Maintenance of normal body weight
- 60. Prevention & Care • High risk strategy : • Increase Physical activity • Reduce over nutrition • Avoid obesity • Stop Alcohol • Avoid diabetogenic drugs • Smoking, Hypertension, elevated cholesterol
- 61. Secondary prevention Aim : • A) to maintain blood glucose levels • B) to maintain ideal body weight Treatment : • Diet alone • Diet & oral anti diabetic drugs • Diet & Insulin
- 63. Self care • Adhere to diet & drugs • Self exam of urine & blood • Avoid alcohol, smoking • S / S of hyper and hypoglycemia • Maintain normal body weight • Maintain identification card • Health education to individual / family
- 64. Tertiary prevention • Prevention of disabilities through complications—blindness, kidney failure, coronary thrombosis, gangrene of lower limbs • Diabetic clinics • Diabetic units • Epidemiological research
- 65. PREVENTION & CONTROL OF OBESITY WEIGHT CONTROL PREVENTION OF OBESITY IN CHILDHOOD & ADOLESCENT DIETARY CHANGES PHYSICAL ACTIVITY OTHERS - APPETITE SUPPRESSING DRUGS - SURGICAL TREATMENT HEALTH EDUCATION