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EPIDEMIOLOGY OF COMMUNICABLE DISEASES - Complete Answers

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1. DOTS (Directly Observed Treatment Short-course) - Tuberculosis

1. Government commitment - Political will and sustained funding
2. Case detection by sputum smear microscopy - Passive case finding among symptomatic patients
3. Standardized short-course chemotherapy - Under direct observation for at least initial 2 months
4. Regular uninterrupted supply of anti-TB drugs
5. Standardized recording and reporting system - for monitoring patient outcomes

• New cases: 2(HRZE)/4(HR) - 2 months intensive phase (Isoniazid + Rifampicin + Pyrazinamide + Ethambutol), followed by 4 months continuation phase (HR)
• Re-treatment: 2(HRZES)/1(HRZE)/5(HRE)

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2. Zoonoses - Definition, Five Examples, and Rabies Management

1. Rabies - caused by Rhabdovirus; transmitted by bite of infected dog/animal
2. Brucellosis - caused by Brucella spp.; from cattle/goat milk/contact
3. Plague - caused by Yersinia pestis; rodent flea bite
4. Leptospirosis - caused by Leptospira; contact with infected animal urine/water
5. Anthrax - caused by Bacillus anthracis; contact with infected animals/hides

• Wash wound thoroughly with soap and water for 10-15 minutes
• Apply 70% alcohol or povidone iodine
• Do NOT suture immediately; if necessary, loosely approximate after RIG infiltration
• Tetanus prophylaxis if needed

• HRIG (Human): 20 IU/kg body weight
• ERIG (Equine): 40 IU/kg body weight
• Infiltrate maximum amount into and around wound; remainder IM at different site from vaccine
• Give on Day 0 only

• Essen regimen (IM): 5 doses on days 0, 3, 7, 14, 28
• Zagreb regimen (IM): 2-1-1 schedule (2 doses on day 0 in each arm, then 1 dose on day 7 and day 21)
• Intradermal (ID): 0.1 ml at 2 sites on days 0, 3, 7, 28 (Thai Red Cross regimen)

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3. End Game Strategic Plan for Polio Eradication

1. IPV introduction: Introduce at least 1 dose of Inactivated Polio Vaccine (IPV) into all routine immunization systems - to provide risk mitigation before OPV withdrawal
2. The Switch (2016): Global synchronized switch from trivalent OPV (tOPV containing types 1, 2, 3) to bivalent OPV (bOPV containing only types 1 and 3) - because no wild poliovirus type 2 has been detected since 1999
3. Why the switch? Risk of Vaccine-Associated Paralytic Poliomyelitis (VAPP) and circulating Vaccine-Derived Poliovirus (cVDPV) from type 2 component now outweighs its benefits
4. Eventual OPV withdrawal: Complete cessation of all OPV use globally after eradication is certified

• All children <15 years with Acute Flaccid Paralysis (AFP) are investigated
• 2 stool samples collected 24-48 hours apart within 14 days of onset
• Non-polio AFP rate target: ≥2 per 100,000 children <15 years
• Adequate stool specimen rate: ≥80%

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4. A Man with Large Lacerated Bleeding Wound from Dog Bite - Management (Rabies PEP)

• This is a Category III exposure (transdermal wound, bleeding, lacerated)
• Assess animal: domestic/stray, behavior, vaccination status, available for observation

1. Wound irrigation - Flush with soap and running water for 10-15 min; apply povidone iodine/spirit
2. Control bleeding - if excessive; do not suture immediately
3. Tetanus toxoid/ATS if not vaccinated
4. Antibiotics to prevent secondary infection (Amoxicillin-clavulanate)

1. RIG (Rabies Immunoglobulin) - ERIG 40 IU/kg or HRIG 20 IU/kg, infiltrated around wound on Day 0
2. Anti-Rabies Vaccine - 5 doses (Essen regimen): Days 0, 3, 7, 14, 28 (IM in deltoid)

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5. Ebola Disease

• Direct contact with blood, secretions, organs, body fluids of infected persons
• Contact with contaminated objects (fomites)
• Healthcare workers at high risk (nosocomial transmission)
• NOT airborne; contact precautions critical

• Sudden fever, fatigue, myalgia, headache, sore throat (early)
• Vomiting, diarrhea, rash, impaired liver/kidney function (later)
• Hemorrhagic manifestations: bleeding from gums, skin, eyes, internal bleeding
• CFR: 25-90% (average ~50%)

• RT-PCR (most reliable), ELISA, virus isolation
• IgM/IgG antibody tests

• No specific approved treatment (supportive care)
• Supportive: IV fluids, electrolyte balance, maintain O2 saturation, treat secondary infections
• Experimental: Zmapp, Remdesivir, monoclonal antibodies (mAb114, REGN-EB3)
• Vaccine: rVSV-ZEBOV (Ervebo) - approved for Zaire strain

• Strict infection prevention and control (IPC) measures
• PPE for healthcare workers
• Safe and dignified burial practices
• Contact tracing and quarantine (21 days)
• Community engagement
• Ring vaccination strategy

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6. Newborn Day 4 - Unable to Suck (Neonatal Tetanus)

• Baby feeds normally for first 2-3 days, then develops inability to suck (trismus/lockjaw)
• Jaw clamping, inability to open mouth
• Muscle spasms (back, abdomen, extremities)
• Seizures triggered by stimuli (light, touch, noise)
• Fever, sweating
• Opisthotonus (arching of back)

• Primarily clinical - no specific lab test needed
• Exclude: birth asphyxia, meningitis, hypocalcemia, hypoglycemia

1. Neutralize toxin: Human Tetanus Immunoglobulin (HTIG) 500 IU IM (or ATS 10,000 IU if HTIG unavailable)
2. Antibiotics: Metronidazole 15 mg/kg loading, then 7.5 mg/kg every 6 hours (7-10 days); OR Penicillin G
3. Control spasms: Diazepam 0.3-0.5 mg/kg IV/rectal every 3-6 hours; or phenobarbitone
4. Wound/umbilical cord care: Clean cord stump with antiseptic; debride if needed
5. Supportive care: Minimize stimulation (dark, quiet room), nasogastric feeding, IV fluids
6. Tracheostomy/ventilation if severe respiratory involvement

1. TT immunization of pregnant mothers - 2 doses TT; if previously vaccinated, 1 booster
2. Clean delivery practices (5 Cleans):
   • Clean hands (birth attendant)
   • Clean delivery surface
   • Clean cutting instrument for cord
   • Clean cord tie
   • Clean cord care
3. Institutional delivery - encourage through schemes like Janani Suraksha Yojana
4. Train traditional birth attendants
5. Avoid harmful cord care practices (applying cow dung, ash - common cause in rural areas)
6. MNT Elimination Programme - India certified MNT eliminated in May 2015 (< 1 case per 1000 live births per district)

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7. Swine Flu (Pandemic H1N1)

• Respiratory droplets (main route), contact with contaminated surfaces
• Human-to-human transmission (unlike avian flu which is mainly bird-to-human)

• Fever >38°C, cough, sore throat, runny nose
• Myalgia, headache, fatigue
• In some: vomiting and diarrhea
• Severe cases: pneumonia, ARDS, multi-organ failure
• High-risk groups: pregnant women, elderly, children <5 yrs, immunocompromised, chronic disease patients

• RT-PCR (gold standard) - nasopharyngeal swab
• Rapid Antigen Test (lower sensitivity)

• Oseltamivir (Tamiflu): 75 mg BD for 5 days (adults); start within 48 hours of symptom onset
• Zanamivir (Relenza): Inhaled, 10 mg BD for 5 days
• Supportive care: hydration, antipyretics

• Influenza vaccine (annual, updated strains)
• Hand hygiene, respiratory etiquette
• Avoid crowded places during outbreak
• Surveillance and quarantine
• India's surveillance: Integrated Disease Surveillance Programme (IDSP)

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8. Rehabilitation in Leprosy

• Reactions management: Prednisolone for Type 1 (reversal) and Type 2 (ENL) reactions
• Eye care: Artificial tears, protective glasses for lagophthalmos; tarsal surgery
• Wound care: Regular dressing, protective footwear for plantar ulcers
• Physiotherapy: Prevent muscle contractures, maintain joint mobility
• Reconstructive surgery: Tendon transfer for claw hand, drop foot correction

• Self-care (SCE): Patients taught to soak, scrub, oil dry hands/feet daily
• Regular inspection for injuries (anesthetic areas cannot feel pain)
• Protective footwear (MCR footwear - microcellular rubber)
• Eye care exercises

• Vocational training and income-generating activities
• Economic assistance, micro-credit schemes
• Integration into mainstream workforce

• Community awareness to reduce stigma and discrimination
• Counseling of patients and families
• Legal protection against discrimination
• Reintegration into family and community

• Counseling, support groups
• Mental health care

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9. AFP (Acute Flaccid Paralysis) Surveillance

• Guillain-Barré Syndrome (most common)
• Transverse myelitis
• Traumatic neuritis
• Other viral infections

1. Case detection - immediate reporting by any health facility
2. Case investigation within 48 hours
3. Collect 2 stool specimens 24-48 hours apart, within 14 days of paralysis onset
4. Ship samples in cold chain to WHO-accredited lab
5. 60-day follow-up to assess residual paralysis
6. Classification committee reviews each case

• Active surveillance: Weekly zero reporting from sentinel sites
• Passive surveillance: Clinicians report AFP cases
• India uses combined active + passive AFP surveillance under Pulse Polio Programme

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10. Child 25 kg Bitten by Stray Dog - Management (Rabies PEP)

1. Wound washing - soap and water 10-15 min; povidone iodine application
2. Assess wound - control bleeding, avoid suturing initially

1. ERIG: 40 IU × 25 kg = 1000 IU infiltrated around wound (Day 0 only)
   • OR HRIG: 20 IU × 25 kg = 500 IU
2. Anti-rabies vaccine - 5 doses on days 0, 3, 7, 14, 28 (deltoid or anterolateral thigh in children <2 yr)
3. Tetanus toxoid if not updated
4. Antibiotics (Amoxicillin-clavulanate)

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11. Toxic Shock Syndrome (TSS)

• Fever: ≥38.9°C
• Rash: Diffuse macular erythroderma (sunburn-like)
• Desquamation: 1-2 weeks after onset (palms, soles)
• Hypotension: SBP ≤90 mmHg (adults)
• Multi-system involvement (3 or more):
  • GI: vomiting, diarrhea
  • Muscular: severe myalgia, CK elevation
  • Mucous membranes: vaginal/oral/conjunctival hyperemia
  • Renal: creatinine ≥2× normal
  • Hepatic: bilirubin/enzymes ≥2× normal
  • Hematologic: platelets ≤100,000
  • CNS: disorientation without fever/hypotension

1. Supportive care: Aggressive IV fluids (resuscitation), vasopressors if needed
2. Remove source: Remove tampon/foreign body, drain abscess, debride infected wound
3. Antibiotics:
   • Cloxacillin/Nafcillin + Clindamycin (clindamycin inhibits toxin production)
   • If MRSA suspected: Vancomycin + Clindamycin
4. IVIG (Intravenous Immunoglobulin) - neutralizes toxin in severe cases

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12. Recent Zoonosis in Orissa (Odisha) - Nipah Virus

• Japanese Encephalitis (endemic in Odisha)
• Anthrax - outbreaks in Odisha (animal-human interface)
• Scrub Typhus - re-emerging

• Reservoir: Fruit bats (Pteropus spp.)
• Transmission: Direct contact with bats/infected pigs, consumption of date palm sap contaminated by bats, person-to-person
• Clinical features: Fever, headache, encephalitis, respiratory illness, altered sensorium
• CFR: 40-75%
• No specific treatment; supportive care; Ribavirin tried
• Monoclonal antibody m102.4 - in trials

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13. Syndromic Approach in STD

• Lab facilities often unavailable at peripheral level
• Many STDs have overlapping clinical presentations
• Early treatment reduces transmission

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14. Strategies for Eradication of Polio

1. Routine immunization with OPV - include all infants
2. National Immunization Days (NIDs) - Pulse Polio Immunization (PPI) - all children <5 yrs get OPV regardless of prior vaccination; 2 rounds/year
3. Sub-national Immunization Days (SNIDs) - in high-risk districts
4. AFP Surveillance - for early detection (as above)
5. Mop-up operations - house-to-house vaccination in areas with confirmed WPV cases
6. Switch strategy - tOPV to bOPV; IPV introduction
7. OPV withdrawal - eventual global cessation once eradicated

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15. Epidemiology of Diarrhoeal Disease

• Safe drinking water (ORS, water purification)
• Sanitation (toilets, hand washing)
• Breastfeeding promotion
• Rotavirus vaccine (in national immunization schedule)
• Zinc supplementation (10 mg/day for children <6 months; 20 mg/day for >6 months, for 14 days)
• ORS for management (low-osmolarity ORS: Na 75, Glucose 75, Cl 65, K 20 - 245 mOsm/L)

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16. STDs of Major Public Health Importance

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17. Post-Exposure Treatment of Dog Bite (SSL Management)

• Category I: Wash only; no vaccine
• Category II: Wound wash + ARV (5 doses)
• Category III: Wound wash + RIG + ARV (5 doses)

• Single-dose ROM therapy: Rifampicin 600mg + Ofloxacin 400mg + Minocycline 100mg (adults)
• For children 5-14 years: Rifampicin 300mg + Ofloxacin 200mg + Minocycline 50mg

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18. Epidemiology of Influenza

• Influenza A: Most virulent; causes epidemics and pandemics; multiple subtypes (H1N1, H3N2, H5N1 etc.)
• Influenza B: Causes epidemics; only humans
• Influenza C: Mild illness; no epidemics

• Antigenic Drift: Minor mutations in H and N antigens; responsible for seasonal epidemics; requires annual vaccine update
• Antigenic Shift: Major reassortment of gene segments between human and animal strains; responsible for pandemics (e.g., 1918 Spanish flu, 1968 Hong Kong flu, 2009 H1N1 pandemic)

• Respiratory droplets (<1 meter)
• Contact with contaminated surfaces
• Airborne in enclosed spaces
• Incubation: 1-4 days

• Influenza vaccine (inactivated, trivalent/quadrivalent) - annual, updated based on WHO surveillance
• Chemoprophylaxis: Oseltamivir 75 mg OD for 10 days post-exposure
• Hand hygiene, masks, respiratory etiquette
• Surveillance: IDSP, sentinel surveillance at hospitals
• ILI (Influenza-Like Illness) and SARI (Severe Acute Respiratory Illness) surveillance

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