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Network Analysis in Community Medicine

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Definition

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The Two Common Types of Network Techniques

1. PERT - Programme Evaluation and Review Technique

• PERT is built around constructing an Arrow Diagram that represents the logical sequence in which events must take place.
• The diagram allows calculation of the time by which each activity must be completed.
• It identifies critical activities (those that cannot be delayed without delaying the whole project).

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2. CPM - Critical Path Method

• The Critical Path is the longest path through the network diagram.
• If any activity along the critical path is delayed, the entire project will be delayed.
• CPM is used to identify which sequence of activities is most time-sensitive.

• PERT focuses on time estimation under uncertainty (used when activity durations are variable).
• CPM focuses on the longest path and is used when activity durations are more predictable.

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How to Construct a Network (Arrow Diagram)

1. List all activities required to complete the project.
2. Determine the sequence and dependencies of activities.
3. Draw arrows representing each activity, with nodes (circles) representing events/milestones.
4. Estimate time for each activity.
5. Calculate the critical path (longest sequence from start to finish).
6. Monitor progress against the network.

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Application in Health Programs

• National Health Programme planning and implementation (e.g., immunization campaigns, malaria control)
• Hospital project management (construction, equipment procurement)
• Disease surveillance and outbreak response coordination
• Training program scheduling
• Research project management

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Context in Park's Textbook

• PPBS (Planning-Programming-Budgeting System) - for resource allocation
• Work Sampling - for measuring staff activity and manpower needs
• Decision Making tools

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Cafeteria Approach in Family Planning

Background - Why It Was Adopted

• Safe and effective
• Acceptable and inexpensive
• Reversible
• Simple to administer
• Independent of coitus
• Long-lasting with minimal medical supervision

• Cultural patterns
• Religious beliefs
• Socio-economic status
• Individual needs and preferences

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Definition - The Cafeteria Approach

"The present approach in family planning programmes is to provide a 'cafeteria choice' - that is, to offer all methods from which an individual can choose according to his needs and wishes, and to promote family planning as a way of life."

• Park's Textbook of Preventive and Social Medicine

"Achieve universal access to information/counselling, and services for fertility regulation and contraception with a wide basket of choices."

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The "Cafeteria" - Available Contraceptive Methods

I. Spacing Methods (Temporary)

II. Terminal Methods (Permanent)

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Key Principles of the Cafeteria Approach

1. No target-based promotion - No single method is pushed on any individual or community.
2. Informed choice - Clients receive counselling on all available methods, including benefits, side-effects, and effectiveness.
3. Continuation rate matters - The success of any method depends not just on its effectiveness but on the rate of continued, correct use.
4. Client-centred care - The decision is made by the couple, not the health worker.
5. Equity of access - Services should be available regardless of socioeconomic status or location.

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Significance in India's Family Planning Programme

• India shifted from target-based (sterilization-heavy) family planning in the 1970s-80s to the cafeteria/target-free approach after the International Conference on Population and Development (ICPD), Cairo, 1994.
• The Reproductive and Child Health (RCH) Programme launched in 1997 formally adopted this approach.
• NPP 2000 reinforced it as a core policy principle.

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Health Hazards of Healthcare Waste

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Introduction

• 75-90% of healthcare waste is non-risk "general" waste (comparable to domestic waste).
• The remaining 10-25% is hazardous and creates a variety of health risks.

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Distribution of Hazardous Waste (WHO Estimate for Developing Countries)

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Characteristics That Cause Hazard

• (a) Contains infectious agents
• (b) Contains toxic or hazardous chemicals, pathological waste, or pharmaceuticals
• (c) Contains sharps (needles, blades, broken glass)
• (d) Is genotoxic (mutagenic/carcinogenic)
• (e) Is radioactive
• (f) Non-hazardous or general waste (lower risk but large volume)

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Groups at Risk

1. Medical doctors, nurses, healthcare auxiliaries and hospital maintenance personnel
2. Patients in healthcare establishments
3. Visitors to healthcare establishments
4. Support service workers - laundries, waste handlers, transporters
5. Waste disposal facility workers - landfill and incinerator workers, including scavengers

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Health Hazards - Detailed

1. Hazards from Infectious Waste and Sharps

• A puncture, abrasion, or cut in the skin
• Mucous membranes
• Inhalation
• Ingestion

• HIV - strong evidence of transmission via healthcare waste
• Hepatitis B and C viruses - strong evidence of transmission
• Antibiotic-resistant bacteria - bacteria resistant to antibiotics and chemical disinfectants add to the hazard

• Can cause needlestick injuries
• Transmits bloodborne pathogens directly
• Affects waste handlers who may not know the contents of disposal bags

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2. Hazards from Chemical and Pharmaceutical Waste

• Toxic chemicals can cause poisoning by absorption through skin, inhalation, or ingestion
• Disinfectants and solvents are corrosive and can cause chemical burns
• Expired or discarded pharmaceuticals may be toxic if misused or ingested
• Cytotoxic (anticancer) drugs are particularly hazardous - even small quantities can be mutagenic and carcinogenic

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3. Genotoxic Hazards

• Genotoxic waste (cytotoxic drugs, vomit/urine/faeces from patients treated with cytotoxic agents, radioactive material) is highly hazardous
• Can damage genetic material (DNA)
• Risk of mutagenicity, teratogenicity, and carcinogenicity in exposed individuals
• Healthcare workers handling antineoplastic agents are at particular risk

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4. Radioactive Hazards

• Waste from radiotherapy, nuclear medicine, and laboratory research contains radioactive isotopes
• Can cause radiation sickness, burns, and increased cancer risk
• Long-term exposure can lead to leukemia and solid tumors
• Requires special containment, labeling, and disposal protocols

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5. Public Sensitivity / Psychological Hazard

• Apart from direct health hazards, the general public is very sensitive to the visual impact of healthcare waste, particularly anatomical waste (body parts, placenta, fetal tissue)
• Improper disposal causes public alarm and loss of trust in health systems

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Summary Table

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Overcrowding

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Definition

Overcrowding refers to the situation in which more people are living within a single dwelling than there is space for, so that movement is restricted, privacy is secluded, hygiene is impossible, rest and sleep are difficult.

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Health Effects

A. Physical Health Effects

• Infectious diseases spread rapidly under conditions of overcrowding.
• Particularly promotes spread of respiratory infections:
  • Tuberculosis (TB)
  • Influenza
  • Diphtheria
  • Meningococcal meningitis
  • COVID-19 and other droplet-spread infections
• High morbidity and mortality rates are observed where housing conditions are substandard.

B. Psychosocial Health Effects

• Irritability
• Frustration
• Lack of sleep
• Anxiety
• Violence
• Mental disorders

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Standards for Overcrowding

1. Persons Per Room

2. Floor Space

Note: A baby under 12 months is not counted; children between 1-10 years are counted as half a unit.

3. Sex Separation

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Diseases Associated with Overcrowding

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Relationship to Social Determinants

• Poverty and low income
• Urban slums and informal settlements
• Population explosion
• Migration to cities
• Inadequate housing policies

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Prevention and Control

1. Urban planning - zoning laws, minimum housing standards
2. Slum clearance and rehabilitation programmes
3. Population control - reducing family size through family planning
4. Building regulations - enforcing minimum floor space per occupant
5. Education on hygiene in crowded settings
6. Surveillance of communicable diseases in high-density areas

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Bias in Epidemiological Research

Definition

Bias is any systematic error in the determination of the association between the exposure and disease. The relative risk estimate may increase or decrease as a result of bias; it reflects some type of non-comparability between the study and control groups.

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Major Categories of Bias

1. Selection Bias

• Healthier (or sicker) individuals are more likely to volunteer or be included
• Non-participation by certain subgroups
• Attrition (loss to follow-up) during the study
• "Depletion of susceptibles" - the most susceptible individuals drop out early in cohort studies
• In case-control studies - improper selection of cases or controls

• Named after Dr. Joseph Berkson
• Arises due to different rates of hospital admission for people with different diseases
• Hospital cases and controls may not represent the general population
• Overestimates or underestimates associations because hospital patients are not typical

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2. Information Bias (Measurement Bias / Misclassification Bias)

• Called measurement error when dealing with continuous variables
• Called misclassification when dealing with categorical/binary variables

• Poorly designed data collection instruments
• Poor execution of study protocols
• Individual subject limitations (memory, social desirability)
• Data entry errors
• Incorrect definition of variables

• Cases and controls are asked about past history
• Cases (e.g., post-MI patients) tend to recall exposure more thoroughly than controls (healthy persons)
• This creates a spurious association between the recalled factor and the disease
• Example: Patients who had a myocardial infarction may remember and report more risk factor exposures than healthy controls

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3. Interviewer's Bias

• Occurs when the interviewer knows the study hypothesis and also knows who the cases are
• May question cases more thoroughly about the suspected causal factor than controls
• Can be detected by comparing the average interview duration for cases vs. controls
• Control: Eliminated by double-blinding (interviewer unaware of case/control status)

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4. Confounding Bias

• A confounder is a variable that is associated with both the exposure and the outcome, and is not an intermediary in the causal pathway
• Confounding creates a spurious or distorted association between exposure and disease
• Can overestimate or underestimate the true association

• At design stage: Randomization, matching, restriction
• At analysis stage: Stratification (Mantel-Haenszel method), multivariate analysis, standardization

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Summary Table of Bias Types

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Direction of Bias

• Bias toward the null - underestimates the true association (makes it look weaker)
• Bias away from the null - overestimates the true association (makes it look stronger)
• Nondifferential misclassification typically biases toward the null
• Differential misclassification can bias in either direction

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Key Principle

Bias is best prevented at study design, not corrected at analysis. Once introduced, systematic error cannot be removed by statistical techniques.

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• Park's Textbook of Preventive and Social Medicine, p. 86 (Bias in Case-Control Studies)
• Firestein & Kelley's Textbook of Rheumatology - Epidemiological Methods (Selection Bias, Information Bias)

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Anemia Mukt Bharat (AMB) / Intensified National Iron Plus Initiative (I-NIPI)

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Objectives (2 marks)

Impact Objective

• Reduction in morbidity and mortality due to anemia.

Outcome Objective

• Reduce anemia prevalence by 3 percentage points per annum in all age groups (children, adolescents, pregnant women, and Women of Reproductive Age/WRA).

Output Objective

• Increase the proportion of eligible beneficiaries who consumed IFA tablets as per protocol by 50% (target set by NFHS-5).

Process Objectives

• Increase community knowledge and risk perception through improved social support.
• Ensure that state governments have enhanced capacity to deliver services and supplies for prevention and management of anemia.

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Key Interventions (4 marks)

1. Prophylactic Iron Folic Acid (IFA) Supplementation

• Universal supplementation across all six target age groups
• Dose adjusted by age group:
  • Children 6-59 months: Syrup IFA 1 mg/kg/day (preventive); 3 mg/kg/day for 2 months (therapeutic)
  • Children 5-9 years: 1 small tablet/week (preventive); 3 mg/kg/day for 2 months (therapeutic)
  • Adolescents 10-19 years: 1 weekly IFA tablet (preventive); 2 tablets/day for 3 months (therapeutic) - given through schools under WIFS
  • Pregnant women: 1 IFA tablet/day for 180 days; Therapeutic: 2 tablets/day
  • Lactating mothers: 1 IFA tablet/day for 180 days
  • WRA (non-pregnant): 1 weekly IFA tablet year-round

2. Deworming (Periodic)

• Albendazole tablets for parasitic worm infections (hookworms, roundworms, whipworms)
• Targets children aged 1-19 years
• Given under the National Deworming Day (biannual)
• Rationale: intestinal parasites cause iron malabsorption and blood loss

3. Intensified Year-Round Behaviour Change Communication (BCC) Campaign - "Solid Body, Smart Mind"

• 360-degree communication campaign creating a Jan Andolan (people's movement)
• Promotes:
  • Compliance with IFA supplementation
  • Appropriate Infant and Young Child Feeding (IYCF) practices
  • Increased intake of iron-rich nutritious foods
  • Delayed cord clamping in newborns (retains ~30 mg extra iron for the baby)
  • Early initiation of breastfeeding
• Channels used: interpersonal communication, mass media, social media, community mobilization

4. Testing of Anemia Using Digital Methods and Point-of-Care Treatment

• Use of digital invasive haemoglobinometer (replaces traditional Sahli's method)
• Enables early, accurate, and field-level diagnosis of anemia
• Immediate point-of-care treatment (therapeutic IFA doses) started on diagnosis
• Special focus on pregnant women and children for early identification
• Enables recording and monitoring of hemoglobin levels digitally

5. Mandatory Provision of IFA-Fortified Foods in Government-Funded Public Health Programmes

• Food fortification with iron and folic acid made mandatory in:
  • Mid-Day Meal (MDM) scheme
  • ICDS (Integrated Child Development Services) / Anganwadi supplementary nutrition
  • PDS (Public Distribution System)
  • Other government-funded nutrition programmes
• Ensures passive, population-level iron intake through food

6. Addressing Non-Nutritional Causes of Anemia in Endemic Pockets

• Special focus on:
  • Malaria (a major cause of hemolytic anemia) - convergence with National Vector Borne Disease Control Programme
  • Hemoglobinopathies (sickle cell anemia, thalassemia) - screening and management
  • Fluorosis - endemic in certain states, causes bone marrow suppression
• Targeted intervention in high-burden, endemic districts

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The 6 × 6 × 6 Strategy (4 marks)

6 BENEFICIARIES  ×  6 INTERVENTIONS  ×  6 INSTITUTIONAL MECHANISMS

"6" Beneficiary Age Groups (Life Cycle Approach)

Together these groups cover ~450 million people - nearly 50% of India's population.

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"6" Interventions

1. Prophylactic IFA Supplementation
2. Deworming with Albendazole
3. BCC Campaign - "Solid Body, Smart Mind" + Delayed Cord Clamping
4. Digital Hemoglobin Testing + Point-of-Care Treatment
5. IFA Fortified Foods in Government Programmes
6. Addressing Non-Nutritional Causes (Malaria, Hemoglobinopathies, Fluorosis)

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"6" Institutional Mechanisms

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Summary Diagram

            ANEMIA MUKT BHARAT
                  6×6×6

    6 Groups → Life Cycle Approach
    6 Interventions → TEST · TREAT · TALK + Supply + Fortify + Non-nutritional
    6 Institutions → Coordination · PMU · AIIMS · Convergence · Supply Chain · Dashboard
    
    TARGET: Reduce anemia by 3% per year

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RMNCH+A Programme and the 5×5 Matrix

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What is RMNCH+A?

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Background and Evolution

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What is the "Plus" in RMNCH+A?

1. Inclusion of adolescence as a distinct life stage for the first time
2. Linking maternal and child health to reproductive health, family planning, adolescent health, HIV, gender, and PC&PNDT
3. Linking home/community-based services to facility-based care
4. Ensuring linkages and referrals between primary (PHC), secondary (CHC), and tertiary (District Hospital) levels

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Core Concept - Continuum of Care

• Different life stages (adolescence → pre-pregnancy → pregnancy → birth → newborn → childhood)
• Different levels (home/community → outreach → facility)

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Central Tenets / Guiding Principles

1. Equity - focused on underserved groups
2. Universal care
3. Entitlement - right to free services
4. Accountability - HMIS-based scorecards and reviews

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Goals and Targets (12th Five Year Plan, 2012-2017)

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High Priority Districts (HPDs)

• 184 districts across 29 states were identified based on weak performance against RMNCH+A indicators
• Special focus given to adolescents, urban poor, and tribal populations
• All RMNCH+A resources and monitoring concentrated in HPDs

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The 5 × 5 Matrix for High Impact RMNCH+A Interventions

"To be Implemented with High Coverage and High Quality"

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THE 5 × 5 MATRIX

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PLUS: Health Systems Strengthening (Cross-cutting 5th column)

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Cross-Cutting Interventions

1. Bring down out-of-pocket expenses by ensuring JSSK, RBSK and other free entitlements
2. ANMs and nurses to provide specialized and quality care to pregnant women and children
3. Address social determinants of health through convergence
4. Focus on un-served and underserved villages, urban slums, and blocks
5. Introduce difficult area and performance-based incentives

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Summary Diagram

           RMNCH+A  5 × 5  MATRIX
    ┌─────────────────────────────────────────────┐
    │   5 THEMATIC AREAS × 5 INTERVENTIONS EACH  │
    ├──────────────┬──────────────────────────────┤
    │ Reproductive │ PPIUCD, Interval IUCD, HDC,  │
    │    Health    │ Nischay Kit, Sterilization    │
    ├──────────────┼──────────────────────────────┤
    │   Maternal   │ MCTS/ANC, High Risk Px,      │
    │    Health    │ EmOC/FRU, Death Review,       │
    │              │ Misoprostol/domiciliary        │
    ├──────────────┼──────────────────────────────┤
    │   Newborn    │ Breastfeeding, HBNC, ENC,    │
    │    Health    │ SNCU, Gentamycin              │
    ├──────────────┼──────────────────────────────┤
    │    Child     │ Compl. feeding, ORS+Zinc,    │
    │    Health    │ Pneumonia, Immunization, RBSK │
    ├──────────────┼──────────────────────────────┤
    │ Adolescent   │ Teen pregnancy, Peer ed.,    │
    │    Health    │ ARSH, NIPI/IFA, Menstrual Hx │
    └──────────────┴──────────────────────────────┘

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• Park's Textbook of Preventive and Social Medicine, pp. 523-524 (RMNCH+A Strategy 2013)
• RMNCH+A Strategic Approach 2013, MoHFW, GoI

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National Vector Borne Disease Control Programme (NVBDCP)

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Introduction

1. Malaria
2. Filariasis (Lymphatic Filariasis)
3. Kala-azar (Visceral Leishmaniasis)
4. Japanese Encephalitis (JE)
5. Dengue
6. Chikungunya

States are responsible for planning, implementation, and supervision.

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Transmission

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Three-Pronged Strategy of NVBDCP

(i) Disease Management

• Early case detection and complete treatment
• Strengthening of referral services
• Epidemic preparedness and rapid response

(ii) Integrated Vector Management (IVM) - Transmission Risk Reduction

• Indoor Residual Spraying (IRS) in high-risk areas
• Insecticide-Treated Bed-Nets (ITNs) / Long-Lasting Insecticidal Nets (LLINs)
• Use of larvivorous fish
• Anti-larval measures in urban areas
• Source reduction and minor environmental engineering

(iii) Supportive Interventions

• Behaviour Change Communication (BCC)
• Public-private partnership and inter-sectoral convergence
• Human resource development through capacity building
• Operational research (drug resistance and insecticide susceptibility studies)
• Monitoring and evaluation through periodic reviews/field visits
• Web-based Management Information System
• Vaccination against Japanese Encephalitis
• Annual Mass Drug Administration (MDA) against lymphatic filariasis

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(A) MALARIA

Historical Milestones

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National Framework for Malaria Elimination in India (2016-2030)

• Eliminate malaria (zero indigenous cases) throughout the entire country by 2030
• Maintain malaria-free status and prevent re-introduction

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Classification of States for Malaria Elimination (2014)

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Surveillance Parameters

• Active Case Detection (ACD): MPWs/ANMs collect blood smears during fortnightly house visits in rural areas
• Passive Case Detection (PCD): Fever cases at sub-centres, malaria clinics, CHCs, hospitals
• RDTs at community level: ASHAs perform rapid diagnostic testing
• ~100 million blood slides examined annually, detecting ~1.5 million malaria cases

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Vector Control (Malaria)

• API ≥ 5: Covered by LLINs
• API ≥ 2: Covered by ITNs + IRS
• IRS insecticides: DDT (first choice); Malathion and synthetic pyrethroids where DDT resistance exists
• DDT: 2 rounds; Malathion: 3 rounds; Synthetic pyrethroids: 2 rounds
• ~80 million population covered by IRS

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Urban Malaria Scheme (Launched 1971)

• Covers 131 towns in 19 states/UTs, protecting 130 million population
• Strategy: Intensive anti-larval measures + drug treatment
• Vectors breed in overhead tanks, water coolers, cisterns, flower vases, old tyres, construction sites
• Civic bye-laws enacted in Delhi, Mumbai, Kolkata, Chandigarh, Bengaluru, Chennai, Ahmedabad, Goa

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Special Strategy for P. vivax Elimination

• Hypnozoites prolong parasite lifespan; difficult to detect
• RDTs for P. vivax less sensitive than those for P. falciparum
• Radical treatment requires 14 days of Primaquine (vs 3 days for P. falciparum)
• Longer incubation period

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Tribal Malaria Action Plan (TMAP)

• Most cases in tribal areas of Odisha, Jharkhand, Chhattisgarh, MP, NE states
• Predominant species: P. falciparum (high mortality)
• Barriers: Inaccessible terrain, poverty, outdoor sleeping, inadequate health infrastructure, triple insecticide resistance
• Special strategy: One-stop centres / mobile clinics on fixed days

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(B) LYMPHATIC FILARIASIS

• National Filaria Control Programme started in 1955
• In 1978, operational component merged with Urban Malaria Scheme
• 250 endemic districts in India

Elimination Strategy

• Single dose of DEC + Albendazole to all eligible population (except pregnant women, children <2 years, seriously ill)
• Conducted for 5 or more consecutive years
• MDA starts in November annually
• Coverage improved from 72.4% (2004) to 86.8% (2014)

• Home-based foot care for lymphoedema cases
• Hydrocele operations scaled up at CHCs/district hospitals
• Line listing of lymphoedema and hydrocele cases (door-to-door survey)

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(C) KALA-AZAR (Visceral Leishmaniasis)

• Endemic in: 33 districts of Bihar, 4 of Jharkhand, 11 of West Bengal, 6 of Uttar Pradesh
• Centrally sponsored programme launched in 1990-91
• Cases reduced from 77,102 (1992) to 5,758 (2017)

Elimination Strategies

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(D) JAPANESE ENCEPHALITIS (JE)

• High-burden states: UP, West Bengal, Assam, Bihar, Karnataka, AP, Tamil Nadu, Maharashtra, Manipur, Haryana, Kerala
• High mortality; survivors have neurological complications

Strategies

1. Vaccination - JE vaccine (SA 14-14-2 live attenuated vaccine) in endemic districts
2. Vector control - Source reduction, environmental management, chemical control, personal protection, legislation
3. Case management - Laboratory diagnosis and clinical management
4. Outbreak response - Epidemic preparedness and media management
5. Capacity building - Training and operational research
6. BCC - Social mobilization, IEC
7. Inter-sectoral coordination - Ministries of Urban Development, Rural Development, Panchayati Raj, Education
8. Monitoring and supervision - Analysis of reports, review, field visits

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(E) DENGUE

• Strategy based on Integrated Vector Management (IVM)

Key Strategies

• Environmental management for source reduction
• Chemical control (larvicides, fogging)
• Personal protection (repellents, clothing)
• Legislation (civic bye-laws against water stagnation) (d) Outbreak response - Epidemic preparedness and media management (e) Capacity building - Training, HR strengthening, operational research (f) BCC - Social mobilization, IEC (g) Inter-sectoral coordination (h) Monitoring and supervision

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(F) CHIKUNGUNYA

• Re-emerged after a gap of three decades
• Debilitating but non-fatal viral illness
• Same vector (Aedes aegypti) as dengue - so vector control strategies are identical
• 521 sentinel dengue surveillance hospitals also conduct chikungunya tests
• Diagnostic kits provided by National Institute of Virology, Pune
• Govt. of India provides logistics and funds to states; monitors situation continuously

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Summary Table - NVBDCP at a Glance

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National AIDS Control Programme (NACP) Phase V

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Full Forms

• ICTC = Integrated Counselling and Testing Centre
• PPTCT = Prevention of Parent-to-Child Transmission (of HIV)

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Milestones of NACP

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NACP Phase V (2021-2026) - Overview

• Type: Central Sector Scheme, fully funded by Government of India
• Budget: ₹15,471.94 crore
• Duration: Financial Year 2021-22 to 2025-26
• Alignment with: UNAIDS Global AIDS Strategy 2021-2026; WHO Global Health Sector Strategies 2022-2030; SDG 3.3 (End AIDS epidemic as public health threat by 2030)

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GOAL of NACP Phase V

End the HIV/AIDS epidemic as a public health threat by 2030, through a comprehensive package of prevention, detection and treatment services, in alignment with the UN Sustainable Development Goal 3.3.

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Five Goals of NACP Phase V

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Specific Objectives of NACP Phase V

(a) HIV/AIDS Prevention and Control

1. 95% of people most at-risk of acquiring HIV infection use comprehensive prevention services
2. 95% of HIV-exposed infants receive appropriate ARV prophylaxis and are confirmed HIV-free at 18 months
3. Achieve dual elimination of vertical transmission of HIV and syphilis (MTCT rate <2%)
4. Achieve universal access to quality STI/RTI services for vulnerable populations

(b) HIV Detection

1. 95% of PLHIV know their HIV status (First 95 of 95-95-95 target)

(c) HIV Treatment and Care

1. 95% of all people diagnosed with HIV receive sustained ART (Second 95)
2. 95% of all people receiving ART achieve viral suppression (Third 95)

(d) Cross-Cutting Objectives

1. Eliminate HIV/AIDS-related stigma and discrimination
2. Ensure all PLHIV enjoy legal protection under the HIV and AIDS (Prevention and Control) Act, 2017
3. Strengthen strategic information systems for evidence-based programme management

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Strategies of NACP Phase V (Detailed)

Strategy 1: Prevention - Reducing New Infections

• Reach Female Sex Workers (FSW), Men who have Sex with Men (MSM), Transgender persons (TG), Injecting Drug Users (IDU), migrants and truckers
• Expand coverage based on population mapping surveys (p-MPSE data)

• Scale up Needle Syringe Exchange Programme (NSEP)
• Expand Opioid Substitution Therapy (OST)
• Collaboration with Ministry of Social Justice and Empowerment

• Universal access to free condoms through public facilities
• Social marketing of condoms

• Customized IEC strategies for different target groups
• Community mobilization and peer educator programmes

• 100% voluntary blood donation
• Mandatory HIV testing of all blood units
• Strengthening Blood Banks and NBTC

• Maintain Designated STI/RTI Clinics (DSRCs)
• Dual testing at HIV counselling and testing sites
• Active case finding for early STI detection
• Update STI management guidelines periodically
• Augment laboratory capacities and supply chain

Strategy 2: Prevention of Parent-to-Child Transmission (PPTCT)

• Universal HIV and syphilis screening of all pregnant women at ANC
• Lifelong ART for all HIV-positive pregnant and breastfeeding women (regardless of CD4 count)
• ARV prophylaxis to all HIV-exposed infants
• Early Infant Diagnosis (EID) by HIV-DNA PCR at 6 weeks
• Family-centric approach (involving spouse/partner)
• Transition from single-dose NVP to triple ARV (Option B+)

Strategy 3: HIV Testing - Expanding Case Detection

• Community-Based Screening - frontline health workers (ANMs) at sub-centre level
• HIV Self-Testing - enabling individuals to test at home
• Index Testing - tracing and testing sexual partners and children of PLHIV
• Social Network Testing
• Sampoorna Suraksha Kendras (SSK) - Single-window centres integrating prevention-test-treat-care continuum (new in NACP V)

Strategy 4: Treatment, Care and Support (95-95-95)

• Test and Treat Policy - ART initiated regardless of CD4 count
• Universal Viral Load Testing
• Mission Sampark - tracing defaulters and lost-to-follow-up patients
• Transition to Dolutegravir (DTG)-based treatment regimen (better efficacy, tolerability)
• Free lifelong standardized ART, CD4 testing, viral load monitoring
• Prevention, diagnosis and management of opportunistic infections
• Co-trimoxazole prophylaxis (CPT)
• Integrated HIV-TB services
• Linkage to social protection schemes

Strategy 5: Enabling Environment

• Full implementation of HIV and AIDS (Prevention and Control) Act, 2017 as cornerstone
• Address stigma and discrimination through legal framework and community mobilization
• Involvement of PLHIV networks in programme planning and delivery
• Grievance redressal mechanisms for PLHIV

Strategy 6: Health Systems Strengthening

• Capacity building of health personnel
• Supply chain management for ARV drugs, test kits, condoms
• Web-based Management Information System and data quality
• Public-private partnership engagement
• Integration with NHM/NRHM services

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8 Guiding Principles of NACP Phase V

1. People-centred approach
2. Equity and inclusion
3. Rights-based approach
4. Evidence-informed programming
5. Multi-sectoral partnership
6. Sustainability and ownership
7. Accountability and transparency
8. Innovation and adaptive learning

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ICTC - Integrated Counselling and Testing Centre

Definition and Purpose

• Client-initiated (of their own free will), or
• Provider-initiated (as advised by a medical provider - PITC)

Functions of ICTC

1. Early detection of HIV infection
2. Provision of basic information on modes of transmission and prevention of HIV/AIDS
3. Promoting behavioural change and reducing vulnerability
4. Linking PLHIV to prevention, care and treatment services
5. PPTCT services to pregnant women
6. HIV-TB collaborative testing activities

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Types of ICTC

A. Fixed Facility ICTCs

• High client load centres
• Full-time dedicated counsellor + laboratory technician
• Located at: Medical colleges, District hospitals, Sub-district hospitals, CHCs
• Provide complete HIV counselling and testing services

• Set up below block level at 24×7 PHCs
• Existing health facility staff trained in HIV counselling and testing
• Logistic support provided by DAC (Department of AIDS Control)
• Sustainable, scalable model

• Established in private hospitals, laboratories, NGOs
• Supported by DAC/SACs with:
  • Supply of rapid HIV testing kits
  • Training of staff
  • Quality assurance
  • Protective kits and PEP drugs
  • IEC materials (flip charts, posters)

B. Mobile ICTC

• A van with examination room, counselling space, and blood collection/processing facility
• Team: Health educator/ANM + Counsellor + Laboratory Technician
• Operates in hard-to-reach areas with flexible hours
• Services provided: HIV testing, STI/RTI management, routine health check-ups, ANC, immunization

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Activities Carried Out at ICTC

Pre-Test Counselling

1. Establishing rapport with the client
2. Explaining what HIV/AIDS is - transmission modes, natural history
3. Assessing the client's risk behaviour
4. Explaining the HIV test procedure, its meaning, benefits
5. Addressing fears and misconceptions
6. Ensuring informed consent before testing
7. Discussing confidentiality and its limits

HIV Testing

1. Collection of blood sample
2. Testing using 3-test algorithm (3 ELISA/Rapid tests done sequentially for diagnosis):
   • First test (highly sensitive screening)
   • Second test (confirmatory)
   • Third test (tie-breaker if 1st and 2nd disagree)
3. Recording results in confidential registers
4. Maintaining confidentiality at all times

Post-Test Counselling (HIV Negative)

1. Informing the client of negative result
2. Explaining the window period (and repeat testing if recent exposure)
3. Counselling on risk reduction and safe sexual practices
4. Condom promotion and demonstration
5. Referral for further services if needed

Post-Test Counselling (HIV Positive)

1. Disclosure of result - empathetically, in private
2. Psychosocial support - emotional support, addressing suicidal ideation
3. Information on meaning of HIV positive result vs AIDS
4. Explanation of ART, its availability, and importance
5. Linkage to ART centre for treatment initiation
6. Partner notification counselling and index testing
7. Referral to PLHIV support groups/networks
8. Counselling on positive prevention (preventing transmission to others)
9. Information on legal rights under HIV Act, 2017

PPTCT Services at ICTC

1. Routine HIV counselling and testing of all pregnant women with 'opt-out' option
2. Spouse involvement and family-centric approach
3. Initiation of lifelong ART for HIV-positive pregnant women (TDF + 3TC + EFV)
4. ARV prophylaxis to HIV-exposed infants (NVP syrup)
5. Promotion of institutional delivery
6. EID (Early Infant Diagnosis) referral at 6 weeks (HIV-DNA PCR)
7. Co-trimoxazole prophylaxis for exposed infants
8. Counselling on infant feeding (exclusive breastfeeding recommended for HIV+ mothers on ART)
9. Follow-up at 6 weeks, 6 months, 12 months, 18 months

Other Activities

• HIV-TB collaborative testing - testing TB patients and presumptive TB cases for HIV
• Community outreach by ICTC counsellors to motivate HRGs
• Follow-up of PLHIV for retention in care
• Maintaining records and reporting to NACO via HMIS
• Quality assurance through NACO QMS framework

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PPTCT Programme - Key Features

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Current Status (NACP V Period)

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• Park's Textbook of Preventive and Social Medicine, pp. 489-493 (NACP, ICTC, PPTCT)
• NACO - NACP Phase V
• GSACS NACP Phase V Overview

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Herd Immunity

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Definition

Herd immunity (also called community immunity) describes a type of immunity that occurs when the vaccination of a sufficient proportion of a population (the "herd") provides indirect protection to unprotected individuals.

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Mechanism

IMMUNE person → CANNOT transmit → Susceptible person is protected indirectly

When most people are immune:
Infectious person → Mostly contacts IMMUNE people → Chain breaks → Epidemic dies out

• If R₀ > 1 → epidemic spreads
• If R₀ < 1 → epidemic dies out
• Herd immunity reduces the effective reproduction number (Rₑ) to < 1

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Herd Immunity Threshold (HIT)

HIT = 1 - (1/R₀)

It is neither possible nor necessary to achieve 100% herd immunity to halt an epidemic or control disease - as demonstrated by the eradication of smallpox and poliomyelitis.

• Virulence of the disease
• Efficacy of the vaccine
• Contact parameter for the population

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Examples

Example 1 - Measles in the Faroe Islands (1854) - Classic Example

• When measles was introduced into a "virgin" population (no prior immunity), the attack rate and case fatality rate were very high, involving practically all susceptibles.
• As the epidemic progressed, natural infection built up herd immunity, and the epidemic wave declined when enough people had recovered and became immune.
• This demonstrates how even natural herd immunity (through infection) can terminate an epidemic.

Example 2 - Diphtheria in England and Wales

• When approximately 75% of children were immunized against diphtheria, the disease virtually disappeared from the community.
• This is a textbook example of vaccine-induced herd immunity protecting the whole community.
• Key lesson: "This figure must be maintained - there is no room for complacency."

Example 3 - Smallpox Eradication

• Herd immunity played an important role, but the final eradication of smallpox was achieved through surveillance and containment (elimination of the source of infection) - not herd immunity alone.
• After vaccination was abolished, herd immunity against smallpox has naturally declined over time.

Example 4 - Tetanus - Exception

• Herd immunity does NOT protect individuals against tetanus, because:
  • Tetanus is not spread from person to person
  • Clostridium tetani spores persist in the soil and in animal faeces
  • Protection is entirely individual - every person needs their own vaccine

Example 5 - Poliomyelitis

• High vaccine coverage has interrupted wild poliovirus transmission in most of the world, demonstrating how sustained herd immunity leads to disease elimination.

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Elements That Contribute to Herd Immunity

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Factors Affecting Herd Immunity

1. Infectious Agent-Related Factors

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2. Host (Population) - Related Factors

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3. Herd Structure-Related Factors

• Host population density - Dense populations increase contact rates, requiring higher immunity thresholds
• Mixing patterns - Random mixing vs. clustered/assortative mixing
• Presence of alternative animal hosts - If the pathogen has an animal reservoir, herd immunity in humans cannot eliminate it (e.g., zoonoses)
• Presence of insect vectors - For vector-borne diseases, herd immunity in humans may be insufficient if the vector remains active
• Environmental and social factors - Poverty, sanitation, living conditions that favour or inhibit transmission

"Herd structure is never constant. It is subject to constant variation because of new births, deaths and population mobility."

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4. Immunization Programme Factors

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Herd Immunity Does NOT Work For

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Measurement of Herd Immunity

• Serological surveys (serological epidemiology) - measuring antibody levels in the population to estimate the proportion immune
• Seroprevalence studies are the standard tool

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Summary

KEY FORMULA:  HIT = 1 - (1/R₀)

High R₀ (Measles = 15) → HIT = 1 - (1/15) = 93%
Low R₀ (Flu = 2)       → HIT = 1 - (1/2)  = 50%

Factors LOWERING herd immunity:
→ New births (unvaccinated)
→ Migration of susceptibles
→ Waning immunity
→ Vaccine hesitancy
→ Antigenic drift of pathogen

Factors RAISING herd immunity:
→ Ongoing immunization programmes
→ Natural infection
→ High vaccine efficacy + coverage

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• Park's Textbook of Preventive and Social Medicine, p. 115 (Herd Immunity)
• Roitt's Essential Immunology, p. 2704 (Herd Immunity and Diphtheria)