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1. Kala-Azar: Epidemiology and NVBDCP/NCVBDC Control Strategies

Epidemiology

• Causative organism: Leishmania donovani (an intracellular parasite infecting macrophages)
• Vector: Female sandfly (Phlebotomus argentipes in India)
• In India, kala-azar is an anthroponotic (non-zoonotic) infection - man is the sole reservoir, distinguishing it from other parts of the world where animal reservoirs (dogs, rodents) exist.

• All age groups susceptible; peak age in India is 5-9 years
• Males affected twice as often as females
• Socio-economic status: strikes the poorest sections of society
• Population movement between endemic and non-endemic areas facilitates spread

• Sandfly P. argentipes breeds in dark, damp places with organic debris - cracks in mud walls, rubble, leaf litter
• Rainfall, humidity and temperature influence sandfly breeding density
• Endemic in specific geographical zones of the Indian subcontinent

• Endemic in 33 districts of Bihar, 4 of Jharkhand, 11 of West Bengal, and 6 of Uttar Pradesh
• Sporadic cases in a few other UP districts
• The centrally-sponsored programme launched in 1990-91 brought incidence down from 77,102 cases in 1992 to 5,758 cases in 2017

• Caused by L. donovani; appears 1 to several years after apparent cure
• Multiple nodular infiltrations of the skin without ulceration; parasites numerous in lesions
• Acts as an important human reservoir maintaining transmission

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Strategies for Kala-Azar Elimination under NVBDCP/NCVBDC

• Introduction of rK39 rapid diagnostic kits (immunochromatographic assay; result in 5 minutes)
• Active case searches increased from annual to quarterly, conducted during the "Kala-Azar Fortnight" - door-to-door search by peripheral health workers
• ASHA incentive: Rs. 300 for identifying a case; Rs. 100/Rs. 200 for ensuring one/two rounds of insecticide spraying; patient gets Rs. 500 as daily wage compensation during hospitalization, Rs. 2,000 for PKDL

• Single dose Liposomal Amphotericin B (LAMB) IV: 10 mg/kg bw - drug of choice across all age groups (including paediatric, pregnant, elderly); WHO supplies free of cost
• Miltefosine (oral): Adults >12 yr, weight >25 kg - 100 mg/day (two 50 mg doses) after meals for 28 days; children 2-11 yr - 2.5 mg/kg once daily × 28 days; NOT for pregnant/lactating women
• Amphotericin B deoxycholate: 1 mg/kg bw on alternate days × 15 doses (IV)
• Combination therapy: Paromomycin IM + Miltefosine

• DDT being replaced with synthetic pyrethroid (pyrethroids) for indoor residual spraying (IRS) due to emerging sandfly resistance to DDT
• Indoor residual spray of all villages reporting cases; vegetation, breeding sites, and animal shelters included
• Two rounds of IRS per year recommended

• IEC campaigns; community participation

• Training of health workers and volunteers in case detection

• Key indicators: detection rate, treatment completion rate, coverage rate of vector control, final cure rate, treatment failure rate

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2. Leprosy: Classification, Management, and NLEP

Classification of Leprosy

1. Hypopigmented patches with loss/reduction of sensation
2. Thickened peripheral nerves
3. Presence of AFB in skin smears/nasal smears
4. Acid-fast bacilli on skin biopsy

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Management of Leprosy

Multi-Drug Therapy (MDT) Regimens (WHO-Recommended)

• Rifampicin: 600 mg once monthly (supervised)
• Dapsone: 100 mg daily (self-administered)
• Clofazimine: 300 mg once monthly (supervised) + 50 mg daily (self-administered)
• Duration: 12 months (within 18 months)

• Rifampicin: 600 mg once monthly (supervised)
• Dapsone: 100 mg daily (self-administered)
• Duration: 6 months (within 9 months)

• MB: Rifampicin 450 mg monthly + Dapsone 50 mg daily + Clofazimine 150 mg monthly + 50 mg every other day
• PB: Rifampicin 450 mg monthly + Dapsone 50 mg daily

• Type 1 (Reversal reaction): Treat with corticosteroids (prednisolone)
• Type 2 (ENL): Thalidomide (not in women of childbearing age) or corticosteroids, clofazimine

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National Leprosy Eradication Programme (NLEP)

• National Leprosy Control Programme (NLCP) started in 1955 using DDS (dapsone) monotherapy
• Renamed National Leprosy "Eradication" Programme (NLEP) in 1983 when MDT was introduced
• Goal: reduce prevalence to <1 per 10,000 population
• World Bank support: Phase 1 (1993), Phase 2 (2001-2004)
• Integrated with general health system in 2002-03: leprosy services now available at all PHCs and government hospitals
• Target achieved at national level by December 2005

1. Decentralized, integrated leprosy services through general health care system
2. Capacity building of general health services functionaries
3. Intensified IEC (Information, Education and Communication)
4. Prevention of disability and medical rehabilitation
5. Intensified monitoring and supervision

• Sparsh Leprosy Awareness Campaign: Awareness drives, stigma reduction
• Special action in 209 high-endemic districts; house-to-house surveys in 1792 blocks and 150 urban areas
• Achievement: Case load reduced from 57.6/10,000 in 1981 to <1/10,000 in 2005

1. Interrupt transmission to reduce incidence
2. Treat patients to achieve cure and rehabilitation
3. Prevent the development of deformities

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3. HIV: Modes of Transmission, NACP, and PEP

Modes of Transmission of HIV

1. Sexual Transmission (most common globally)

• Unprotected vaginal, anal, or oral sexual intercourse with an infected person
• Anal intercourse carries the highest risk
• Concurrent STIs (especially ulcerative, e.g., syphilis, herpes) greatly increase transmission risk
• Heterosexual transmission is predominant in India (especially in southern states)

2. Blood-borne Transmission

• Sharing of contaminated needles/syringes (intravenous drug users - IDUs)
• Transfusion of infected blood or blood products
• Use of unsterilized medical/dental instruments
• Occupational exposure (needle-stick injuries in health care workers)
• Organ/tissue transplantation from infected donors

3. Mother-to-Child (Vertical) Transmission

• During pregnancy (transplacental) - accounts for about 5-10%
• During delivery (intrapartum) - the most common route of MTCT
• Through breastfeeding (postnatal) - risk of 10-15% if breastfed

• High viral load in source
• Advanced HIV disease in source
• Low CD4 count
• Presence of genital ulcers/STIs
• Unprotected receptive anal intercourse

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National AIDS Control Programme (NACP)

• Vision: An AIDS-free India
• Goal: Zero new infections, zero AIDS-related deaths, zero AIDS-related stigma and discrimination

1. Reduce 80% new infections by 2024 (baseline 2010)
2. Ensure 95% of estimated PLHIV know their status by 2024
3. Ensure 95% PLHIV have ART initiation and retention by 2024 for sustained viral suppression
4. Eliminate mother-to-child transmission (MTCT) of HIV and syphilis by 2020
5. Eliminate HIV/AIDS-related stigma and discrimination by 2020
6. Facilitate sustainable NACP service delivery through 100% domestic funding by 2024

• <50 cases of congenital syphilis per 100,000 live births
• HIV/AIDS perceived as a chronic, manageable disease without stigma

• States with 'mature' epidemics (high HIV incidence among key populations): targeted interventions
• States with 'emerging' epidemics (rising rates): outreach and prevention
• States with 'low/stable' epidemics: maintain low rates, focus on key populations

• Prevention outreach: Condom promotion, needle/syringe exchange for IDUs (Harm Reduction), Targeted Interventions for high-risk groups (FSW, MSM, IDU, truckers, migrants)
• Testing and counselling: ICTC (Integrated Counselling and Testing Centres); VCTC
• Treatment: Free ART at ART centres nationwide; 95-95-95 target
• PPTCT: Prevention of Parent to Child Transmission - all pregnant women offered HIV testing; nevirapine + AZT prophylaxis; safe delivery; replacement/exclusive breastfeeding
• Care and support: Community Care Centres, Positive Prevention
• IEC/Behaviour Change Communication:
  • Adolescence Education Programme (AEP): 16-hour sessions in schools, Class IX and XI; implemented in 23 states
  • Red Ribbon Clubs (RRCs) in colleges: peer-to-peer messaging, voluntary blood donation
• Surveillance and M&E

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Post-Exposure Prophylaxis (PEP) for HIV

• Healthcare workers after occupational needle-stick/splash exposures
• Non-occupational exposures (sexual assault, unprotected sex, IDU needle sharing)

• Must be started as early as possible, ideally within 2 hours and no later than 72 hours after exposure
• Prophylaxis after 72 hours is NOT recommended
• Duration: 28 days of antiretroviral therapy

1. Nature of exposure (percutaneous > mucous membrane > intact skin)
2. Volume of infectious material
3. Viral load of source patient
4. HIV status of source

• Preferred: Tenofovir (TDF) + Lamivudine (3TC) or Emtricitabine (FTC) + Dolutegravir (DTG) for 28 days
• Alternative: TDF + 3TC + Lopinavir/ritonavir (LPV/r)

1. Immediate local wound care (wash with soap and water for 15 minutes; flush mucous membranes with water)
2. Report to occupational health/emergency immediately
3. Risk assessment
4. Baseline HIV test of exposed person
5. Start PEP (if indicated)
6. Follow-up HIV testing at 6 weeks, 3 months, and 6 months
7. Counselling and psychological support

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4. Rabies: Post-Exposure Prophylaxis after Dog Bite and Prevention/Control

Post-Exposure Prophylaxis (PEP) Following Dog Bite

WHO Wound Category Classification

Steps of PEP

• Immediate, thorough flushing and washing with plenty of soap and water under running tap for at least 15 minutes - this alone can reduce the chance of developing rabies by up to 80%
• If soap unavailable: flush with copious water
• Apply: povidone-iodine (Betadine), or 70% alcohol, or quaternary ammonium compounds
• Suturing should be avoided if possible; if necessary, suture loosely after RIG infiltration
• Anti-tetanus prophylaxis and antibiotics for wound infection as indicated
• Do NOT apply irritants (chilli powder, lime, plant juices) to wound

• Indicated for Category III exposures (and Category II in immunocompromised)
• Administer only once, preferably at or as soon as possible after the first vaccine dose
• NOT indicated after the 7th day (active antibody response is expected to have occurred)
• Dose:
  • Human RIG (HRIG): 20 IU/kg body weight
  • Equine RIG (ERIG)/F(ab')2 products: 40 IU/kg body weight
• As much as anatomically possible should be infiltrated into/around the wound; remaining RIG given IM at a site distant from vaccine
• ERIG: small risk of anaphylaxis (1/45,000); skin test NOT reliable - give regardless

• Purified Chick Embryo Cell Vaccine (PCECV)
• Human Diploid Cell Vaccine (HDCV)
• Purified Vero Cell Vaccine (PVCV)

• Day 0: 2 sites ID
• Day 7: 1 site ID
• Day 21: 1 site ID

• Only 2 doses (days 0 and 3); RIG NOT required

• Full 5-dose IM course + RIG for Category II and III exposures
• Check antibody titres 2-4 weeks after vaccination

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Prevention and Control of Rabies

1. Prevention in Humans (Pre-exposure Prophylaxis)

• Laboratory workers handling rabies virus/lyssaviruses
• Veterinarians and animal handlers
• Children in rural high-risk areas
• Travellers with extensive outdoor exposure

2. Animal Reservoir Control

• Elimination of stray and ownerless dogs combined with mass immunization of at least 80% of the entire dog population in the shortest possible time
• Registration and licensing of all domestic dogs
• Restraint of dogs in public places
• Immediate destruction of dogs and cats bitten by rabid animals
• Quarantine (~6 months) of imported dogs
• Health education about care of dogs

• Oral vaccine baits placed in fox habitats (successful in Canada, Germany, Switzerland)
• Wildlife population control

3. Health Education

• Teaching public to avoid contact with unknown animals
• Reporting all bites promptly

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5. Acute Encephalitis Syndrome (AES): Definition, Causes, Diagnosis, and Management

Definition

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Case Classification

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Causes of AES

• Japanese Encephalitis (JE) virus - single-stranded RNA virus, commonest identifiable cause in India
• Enteroviruses (EV71, Coxsackievirus A16)
• Herpes Simplex Virus (HSV-1, HSV-2)
• Dengue virus
• Nipah virus
• West Nile virus
• Influenza viruses
• Measles, Mumps, Varicella, Rabies

• Bacterial meningitis (Neisseria meningitidis, Streptococcus pneumoniae, H. influenzae)
• Tuberculous meningitis

• Cerebral malaria (P. falciparum) - AES with symmetrical signs and fever suggests this
• Cerebral cysticercosis

• Scrub typhus (Orientia tsutsugamushi)
• Lychee fruit toxicity (hypoglycin A) - linked to Muzaffarpur, Bihar outbreaks

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Diagnosis

• Acute fever + altered sensorium (>2 hours duration with focal seizure or paralysis) = encephalitis in epidemic setting

• IgM Capture ELISA for JE/Enterovirus - preferred in sentinel surveillance network
• Virus isolation: National Reference Laboratory
• CSF examination (cell count, protein, glucose, culture)
• Blood smear/RDT for malaria
• Blood culture, scrub typhus serology
• Blood glucose (to exclude hypoglycaemia)
• CT/MRI brain

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Management (NVBDCP Guidelines 2014)

1. Identify danger signs: abnormal posturing, apnoea, Cheyne-Stokes breathing, papilloedema, focal neurological deficit
2. Maintain airway; Oxygen therapy
3. Control seizures: Diazepam IV/rectal (first line); Phenobarbitone
4. Reduce fever: Paracetamol; tepid sponging
5. Maintain blood glucose - give IV glucose if hypoglycaemic
6. Refer to FRU/district hospital - early referral is key

• Maintain blood pressure at ~95th centile for age (use dopamine drip if needed) - autoregulation failure makes cerebral circulation dependent on systemic BP
• Avoid fluid overload (risk of cerebral oedema)
• Manage raised intracranial pressure: head elevation 30°, mannitol
• Nutritional support (nasogastric feed if unconscious)
• Prevent infections: mouth care, bladder care, pressure sores

• HSE: Acyclovir IV 10 mg/kg 8-hourly × 14-21 days
• Bacterial meningitis: Appropriate antibiotics
• Cerebral malaria: Artesunate IV
• Scrub typhus: Doxycycline
• Hypoglycaemia: IV dextrose

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6. Nosocomial (Hospital-Acquired) Infections: Sources, Prevention and Control

Definition

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Sources of Nosocomial Infections

1. Sources

• Patients suffering from infectious diseases: viral infections (measles, rubella, influenza, viral hepatitis), skin infections (discharging wounds, infected lesions, eczema, psoriasis, boils, bed sores), respiratory infections (pulmonary TB, sore throat, chest infections), and urinary tract infections

• Doctors, nurses, ward boys in close contact with patients can transmit infection
• Staphylococcus aureus nasal carriage in staff is a classic example
• Staff with skin diseases, sore throat, diarrhoea, or other infections are a risk

• Inanimate environment: contaminated linen, clothing, bedpans, floors, walls
• Air: Hospital air contaminated with dust (bacteria, viruses released during sweeping, dusting, bed-making)
• Water and food: Contaminated water/food supply
• Medical equipment: Catheters, endoscopes, IV lines, ventilators
• Medications: Contaminated IV fluids or medications

• Endemic: Most common; constant background level of HAI
• Epidemic: Unusual increase above baseline of a specific infection/organism; constitutes an outbreak

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Routes of Spread

1. Contact transmission (most common): Direct contact (hands of staff) or indirect contact (contaminated instruments/surfaces)
2. Droplet transmission: Large respiratory droplets from coughing/sneezing (TB, influenza, measles)
3. Airborne transmission: Small particles remaining suspended in air (TB, chickenpox, measles)
4. Vehicle transmission: Contaminated food, water, medications, blood products
5. Vector-borne: Rare in hospital settings

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Prevention and Control

Specific Measures

• Infectious patients must be isolated; susceptible patients should not be placed next to infectious patients
• Intensive care units, urological wards, geriatric wards, and special baby care units - highest risk

• Staff with skin diseases, sore throat, cold, ear infection, diarrhoea should be kept away from work until cured
• Regular changes of aprons and outer clothing; personal hygiene

• Hands are the most common route of cross-infection
• Thorough hand-washing with soap and water; alcohol-based hand rub when hand-washing insufficient
• WHO guidelines: "Clean Care is Safer Care" (2009)
• WHO's "5 Moments for Hand Hygiene": before patient contact, before aseptic procedure, after body fluid exposure, after patient contact, after contact with patient surroundings

• Hospital dust contains numerous bacteria and viruses
• Wet dusting and vacuum cleaning (suppress dust during sweeping/dusting/bed-making)

• Proper disinfection of articles used by patients (urine, faeces, sputum)
• Sterilization of surgical instruments (autoclave, ETO, glutaraldehyde)
• Spaulding classification: Critical items (sterilize) > Semi-critical (high-level disinfection) > Non-critical (low-level disinfection)

• Face masks, proper bed spacing (minimum 1 metre)
• Prevention of overcrowding; adequate lighting and ventilation
• Negative-pressure isolation rooms for airborne infections (TB, measles)

• Barrier nursing (protective isolation)
• Task nursing to minimize cross-infection

Standard (Universal/Routine) Precautions

• Gloves for all contacts with secretions, body fluids, blood, mucous membranes
• Gown, mask, eye protection where contamination of clothes/face is anticipated

1. Urinary tract infections (catheter-associated)
2. Surgical wound infections
3. Pneumonia (ventilator-associated)
4. Primary bloodstream infections (central line-associated)

Administrative Measures

• Hospital Infection Control Committee: formulates policies on admission of infectious cases, isolation facilities, disinfection procedures
• Antibiotic stewardship programmes
• Surveillance of HAI rates
• Regular audit and feedback

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7. Emerging and Re-emerging Infectious Diseases

Definitions

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Causes / Determinants

1. Microbial/Agent Factors

• Genetic mutations and evolution: Rapid mutation rates (especially RNA viruses like influenza) lead to new strains evading host immunity (e.g., influenza pandemics)
• Antigenic shift and drift in influenza
• Antimicrobial resistance (e.g., MDR-TB, MRSA, XDR TB, carbapenem-resistant Enterobacteriaceae - CRE, drug-resistant N. gonorrhoeae)
• Recombination between animal and human viral strains

2. Host Factors

• Increased immunocompromised populations: HIV/AIDS, organ transplants, cancer chemotherapy - susceptibility to opportunistic infections
• Ageing populations: Greater susceptibility
• Behavioural factors: Sexual practices, IVDU, bushmeat hunting

3. Environmental/Ecological Factors

• Deforestation and land use change: Bringing humans into contact with new animal reservoirs (Nipah, Ebola, Hendra)
• Climate change: Expanding the geographic range of vector-borne diseases (dengue, Zika, chikungunya, Lyme disease)
• Agricultural practices: Factory farming, use of antibiotics in livestock

4. Human/Social Factors

• International travel and trade: Rapid global spread of pathogens (SARS, COVID-19, influenza pandemics)
• Urbanization: High-density populations, inadequate sanitation
• Population displacement: Refugees, migrants moving pathogens across borders
• Breakdown of public health infrastructure: Re-emergence of previously controlled diseases
• Bioterrorism: Deliberate release of agents (anthrax, smallpox concerns)

5. Healthcare/Technological Factors

• Medical procedures introducing new transmission routes (blood transfusion → HIV, hepatitis B; organ transplants → CMV, West Nile virus)
• Hospital environments fostering antimicrobial resistance

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Examples

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Control Measures

1. Surveillance and Detection

• Global surveillance networks: WHO Global Outbreak Alert and Response Network (GOARN), IHR (International Health Regulations 2005)
• Enhanced sentinel surveillance at entry points (airports, seaports)
• Early warning systems; event-based surveillance
• Laboratory capacity building for rapid pathogen identification

2. Prevention of Spread

• Quarantine and isolation during outbreaks
• Infection prevention and control (IPC) in health facilities
• Vector control: insecticide use, environmental management
• Travel advisories and screening at ports of entry
• Safe food handling and food safety regulations

3. Response Measures

• Rapid response teams (national and international)
• Contact tracing and ring vaccination
• Stockpiling of vaccines, antivirals, and PPE
• Emergency use authorization of investigational vaccines/treatments (e.g., Ebola vaccines)

4. Research and Development

• Development of broad-spectrum antivirals and new vaccines
• One Health approach: integrated human-animal-environment health surveillance
• International collaboration: CEPI (Coalition for Epidemic Preparedness Innovations), GAVI

5. Antimicrobial Resistance (AMR) Control

• Antibiotic stewardship programmes
• Restricting antibiotic use in agriculture
• Surveillance of resistance patterns (WHO GLASS)
• Development of new antibiotics and alternatives

6. Addressing Root Causes

• Sustainable land use and deforestation control
• Climate change mitigation
• Poverty reduction and improved sanitation
• Strengthening health systems in low- and middle-income countries

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Quick Reference Summary Table