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National Health Programmes of India (PSM)

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Overview

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A. COMMUNICABLE DISEASE PROGRAMMES

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1. National TB Elimination Programme (NTEP)

• Launched: National TB Programme (NTP) 1962; RNTCP revitalized 1993; renamed NTEP 2020
• Goal: Eliminate TB by 2025 (ahead of global target of 2030)
• Strategy: DOTS (Directly Observed Treatment Short-course)

1. Political will and administrative commitment
2. Diagnosis by quality-assured sputum smear microscopy
3. Adequate supply of quality-assured short-course chemotherapy
4. Directly Observed Treatment (DOT)
5. Systematic monitoring and accountability

1. At least 85% cure rate of infectious TB cases
2. Detection of at least 70% of estimated cases by quality sputum microscopy

• Pursuing quality DOTS expansion
• Addressing TB/HIV and MDR-TB
• Contributing to health system strengthening
• Engaging all care providers
• Empowering patients and communities
• Enabling and promoting research

• Reduce TB incidence to 44/1,00,000
• Reduce TB mortality to 3/1,00,000
• Zero catastrophic expenditure for TB patients

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2. National AIDS Control Programme (NACP)

• Launched: 1987
• Implementing body: NACO (National AIDS Control Organization) - a separate wing under MoHFW

• IEC for STIs/HIV prevention
• PPTCT (Prevention of Parent to Child Transmission) services
• Condom promotion and distribution to high-risk groups
• Linkage with VCTC at district level
• Pre and post-test counselling

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3. National Leprosy Eradication Programme (NLEP)

1. Health education to community regarding leprosy
2. Diagnosis and management of leprosy, reactions, and complications
3. Training of patients with ulcers for self-care
4. Counselling for regularity/completion of MDT (Multi-Drug Therapy)

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4. National Programme for Control of Blindness (NPCB)

• Launched: 1976 (100% centrally sponsored; incorporated trachoma control programme of 1968)
• Goal: Reduce blindness prevalence from 1.4% to 0.3%
• Current prevalence: 0.36% (2015-19 survey)

1. 66 lakh cataract operations per year
2. School eye screening + 9 lakh free spectacles/year for refractive errors
3. 50,000 donated eyes/year for keratoplasty

• Free cataract surgery through NGO + private practitioners
• Screening of population above 50 years
• Refractive error correction in school children
• Regional Institutes of Ophthalmology as Centres of Excellence
• Public-private partnership for underserved areas

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5. National Vector-Borne Disease Control Programme (NVBDCP)

• Malaria - previously National Malaria Eradication Programme (NMEP, 1958), modified to National Malaria Control Programme
• Filaria - National Filaria Control Programme
• Dengue, Chikungunya, JE (Japanese Encephalitis), Kala-azar

• Symptomatic treatment for suspected JE and dengue
• Complete treatment for Kala-azar cases (as per national policy)
• Treatment of microfilaria-positive cases with DEC + Albendazole
• Mass Drug Administration (MDA) for lymphatic filariasis
• Morbidity management of lymphoedema cases

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6. National Programme for Prevention and Control of Deafness (NPPCD)

1. Early detection of hearing impairment and referral
2. Basic treatment of common ear diseases (wax, otomycosis, otitis externa, otitis media)
3. IEC for prevention and early detection of hearing impairment

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B. NON-COMMUNICABLE DISEASE PROGRAMMES

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7. National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS)

• Background: NCDs accounted for 60% of deaths in India (2016). National Programme for Diabetes, CVD, and Stroke was later integrated with National Cancer Control Programme.
• Coverage: 11th Plan - 100 districts in 21 states; 12th Plan - all districts of India

• Prevent and control NCDs through behaviour and lifestyle changes
• Provide early diagnosis and management
• Build capacity at all healthcare levels
• Train health manpower (doctors, paramedics, nurses)
• Establish palliative and rehabilitative care

• Opportunistic screening of persons above 30 years of age
• NCD Clinics at CHC and district level
• Mass media and IEC for behavioural change
• Implementation through 20,000 sub-centres and 700 CHCs

• IEC for cancer prevention and warning signs
• Early detection of cancer (warning signals: change in bladder/bowel habits, etc.)
• Referral for confirmation and treatment

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8. National Mental Health Programme (NMHP)

• Launched: 1982
• Coverage: 517 districts in 36 states
• Purpose: Ensure mental health care for all, especially underprivileged; integrate mental health into general health care

1. Prevention and treatment of mental/neurological disorders and disabilities
2. Use of mental health technology to improve general health services
3. Application of mental health principles in national development

1. Ensure minimum mental health care for vulnerable/underprivileged populations
2. Encourage application of mental health knowledge in general health care and social development
3. Promote community participation in mental health services

1. Integration with primary health care through NMHP
2. Provision of tertiary care institutions
3. Eradicating stigmatization; protecting rights via Central/State Mental Health Authorities

• Training at nodal institutes
• Public education - awareness and stigma reduction
• OPD and indoor services for early detection and treatment
• Data collection for planning, research, and improvement

• School mental health services (life skills education, counselling)
• College counselling services
• Workplace stress management
• Suicide prevention services (helplines, counselling centres)

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C. MATERNAL, CHILD HEALTH AND FAMILY WELFARE

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9. National Family Welfare Programme

• Launched: 1952 - India was the FIRST country in the world to launch a national family planning programme
• Evolved through successive five-year plans
• 1966: Separate Department of Family Planning created
• 1977: Renamed "Family Welfare" (voluntary basis; no coercion)
• 1985-86: Universal Immunization Programme (UIP) started
• 1992: Child Survival and Safe Motherhood (CSSM) Programme
• 1994 (Cairo ICPD): Integrated as Reproductive and Child Health (RCH) Programme
• Currently under National Health Mission (NHM)

• NRR = 1 by year 2000
• Birth rate of 21 per 1000
• Death rate of 9 per 1000
• Couple protection rate of 60%

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D. ELDERLY AND SPECIAL POPULATION

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10. National Programme for Health Care of the Elderly (NPHCE)

• Launched: 11th Five Year Plan, initially in 100 districts of 21 states
• Aim: Provide separate, specialized, comprehensive healthcare to senior citizens at all levels of the health care delivery system

• 8 regional geriatric centres as referral units
• Geriatric Departments at 20 super-specialized institutions (30-bed inpatient facility)
• Geriatric units at district hospitals (10-bed ward + dedicated OPD)
• Rehabilitation units at CHCs (dedicated elderly health clinics twice a week)
• 2 National Centres of Ageing (NCA) at AIIMS New Delhi and Madras Medical College, Chennai

• Preventive and promotive care
• Management of illness
• Health manpower development for geriatric services
• Medical rehabilitation and therapeutic intervention
• IEC activities

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E. ENVIRONMENTAL HEALTH PROGRAMMES

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11. National Water Supply and Sanitation Programme

• Initiated: 1954
• Renamed: Rajiv Gandhi National Drinking Water Mission (1991) → Swajaldhara (2002) → National Rural Drinking Water Programme (NRDWP) from April 2009 (now a component of Bharat Nirman)

• 40 litres of safe water per capita per day
• At least 1 hand pump/spot source per 250 persons

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F. OTHER NATIONAL PROGRAMMES (at PHC level)

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Quick Exam Summary Table

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NTEP (National TB Elimination Programme) - Complete Notes

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1. HISTORY & EVOLUTION

Mnemonic: "Never Repeat, Stop Ending" = NTP (1962) → RNTCP (1993) → STOP TB (2006) → END TB (2015) → NTEP (2020)

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2. MAGNITUDE OF THE PROBLEM

• ~10 million new TB cases/year (2019)
• 1.2 million TB deaths among HIV-negative + 208,000 among HIV-positive
• 1/3 of world population infected asymptomatically; 5-10% develop clinical disease
• One infectious PTB patient can infect 10-15 persons per year
• MDR/RR-TB: 3.3% of new cases, 18% of retreatment cases

• India has the highest TB burden globally
• Primary MDR-TB: ~2.8%
• Drug resistance in re-treatment cases: 12% (10-13%)

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3. PROBLEM STATEMENT - MNEMONIC

"5-10% of Infected will get Disease; 10-15 contacts per case"

• 5-10% of asymptomatically infected persons develop clinical TB in their lifetime
• One case infects 10-15 contacts per year

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4. CASE DEFINITIONS (2013 WHO, adopted by NTEP)

A. By Bacteriology:

B. By Anatomical Site:

• PTB (Pulmonary TB): Lung parenchyma or tracheobronchial tree; miliary TB = PTB
• EPTB (Extrapulmonary TB): Pleura, lymph nodes, abdomen, GUT, skin, joints/bones, meninges
• Patient with both PTB + EPTB → classified as PTB

C. By Treatment History:

D. By Drug Resistance:

• DS-TB: Drug sensitive
• MDR-TB: Resistant to at least INH + Rifampicin
• RR-TB: Rifampicin resistant (by any method)
• XDR-TB: MDR-TB + resistant to any fluoroquinolone + any second-line injectable

Mnemonic for DR types: "My Rifle eXpired"

• MDR = INH + Rifampicin
• RR = Rifampicin alone
• eXDR = MDR + FQ + injectable

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5. DOTS STRATEGY

Classic DOTS (5 Components)

Mnemonic: "PDASS" = Political Diagnosis Adequate DOT Systematic

1. Political will and administrative commitment
2. Diagnosis by quality-assured sputum smear microscopy
3. Adequate supply of quality-assured short-course chemotherapy drugs
4. Directly Observed Treatment (DOT)
5. Systematic monitoring and accountability

STOP TB Strategy (2006) - 6 Components

Mnemonic: "PAC-EEE" - Pursue, Address, Contribute, Engage, Empower, Enable

1. Pursuing quality DOTS expansion and enhancement
2. Addressing TB/HIV and MDR-TB
3. Contributing to health system strengthening
4. Engaging all care providers
5. Empowering patients and communities
6. Enabling and promoting research

End TB Strategy (2015) - 3 Pillars

Mnemonic: "I-B-I" = Integrated, Bold, Intensified

1. Integrated, patient-centred care and prevention
2. Bold policies and supportive systems
3. Intensified research and innovation

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6. END TB TARGETS

India's NTEP target: Eliminate TB by 2025 (5 years ahead of global target of 2030)

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7. CASE FINDING

Types:

1. Passive Case Finding: Patient presents on own initiative with symptoms (>60% seek care on their own)
2. Intensified/Active Case Finding (ICF): Provider-initiated, targets vulnerable/high-risk groups

Screening Strategies:

• Community screening: mobile/fixed facility, door-to-door
• Institutional screening: hospitals, congregate settings (prisons, refugee camps, old-age homes, workplaces)

Diagnostic Algorithm for Pulmonary TB (NTEP):

1. All presumptive TB → Sputum smear (ZN/LEDFM) + CXR
2. Smear positive + CXR suggestive → Microbiologically confirmed TB
3. Smear negative + CXR suggestive → CBNAAT
   • MTB detected + Rif sensitive → Microbiologically confirmed DS-TB
   • MTB detected + Rif resistant → Manage as Rif-resistant TB
   • MTB not detected → Consider alternate diagnosis; if clinical suspicion high → Clinically diagnosed TB
4. All PLHIV (People Living with HIV) → Fast-track to CBNAAT

Mnemonic: "Smear-X-CBNAAT" = Always start with smear + CXR; escalate to CBNAAT when needed

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8. ANTI-TUBERCULOSIS DRUGS

First-Line Drugs

Mnemonic: "RHZE + S" (Remember How Zebras Eat Straw)

Key Drug Points (high-yield):

• Rifampicin: Only drug active against "persisters"/dormant bacilli in caseous lesions; turns urine red (compliance test); never restart within 3 weeks if stopped (hypersensitivity risk)
• INH: Most distributed drug; crosses BBB and placenta; single daily dose preferred; peak level at 1-2 hours
• Pyrazinamide: Active in acidic pH (intracellular environment); used only in intensive phase
• Ethambutol: Bacteriostatic; causes optic neuritis (check visual acuity before starting)
• Streptomycin: Injectable; ototoxicity + nephrotoxicity; NOT in pregnancy (VIII nerve damage in fetus)

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9. TREATMENT REGIMENS (NTEP - Daily Dose, 2019)

Fixed Dose Combinations (FDCs) in NTEP:

Mnemonic for IP: "HAZE" = H + R + Z + E (four drugs Haze the bug) Mnemonic for CP: "HRE" = Stay calm and "HERE" without Z

Standard Regimens:

• Daily dose regimen replaced the old thrice-weekly intermittent regimen in NTEP
• Drugs given in patient-wise boxes with complete course

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10. TREATMENT OUTCOMES (Definitions)

Mnemonic: "CDFLT" = Cured, Done, Failed, Lost, Transferred"

• Treatment success rate: ≥85% for smear-positive cases
• Case detection rate: ≥70% of estimated cases

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11. MDR-TB MANAGEMENT

Causes of MDR-TB ("Man-made phenomenon"):

Mnemonic: "3 Ps cause MDR" = Poor Provider, Poor Pills, Poor Patient compliance

Drug Grouping for Longer MDR-TB Regimens:

Mnemonic for Group A: "My Best Leprosy drugs" = Moxifloxacin/Levo + Bedaquiline + Linezolid

India MDR-TB data:

• Primary MDR-TB: ~2.8%
• Re-treatment MDR-TB: 12%

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12. LATENT TB INFECTION (LTBI) TREATMENT

Who gets treated (High-risk groups):

Mnemonic: "SHIP-DIM" = Silicosis, HIV, Immigrants, Prison, Diabetes, Immunocompromised, Malnutrition/homeless

• HIV + TB co-infected
• Silicosis
• Recent contact with infectious case
• Prisoners
• Immigrants from high to low burden countries
• Homeless persons
• Illicit drug users
• Diabetes, chronic renal failure
• Children <5 years who are household contacts of PTB (high TB burden countries)

Regimens for LTBI:

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13. TB IN SPECIAL SITUATIONS

Childhood TB:

• 6-8% of all TB in age <15 years
• Source: Usually an adult family member (smear-positive PTB)
• Children rarely smear-positive → not major source of transmission
• Risk highest in children <5 years (up to 20% develop disease within 2 years of infection)
• Commonest age: 1-4 years
• India = first country to introduce paediatric patient-wise boxes
• Diagnosis: CBNAAT preferred; Mantoux (2 TU PPD RT23); CXR; culture

TB + HIV:

• All TB patients must be tested for HIV
• HIV-positive TB patients must receive ART + Co-trimoxazole preventive therapy (CPT)
• HIV counselling and testing must NOT delay TB diagnosis

TB + Diabetes:

• Opportunistic screening for DM in all TB patients (blood sugar mandatory)
• DM triples the risk of TB

TB + COVID-19:

• Both respiratory diseases; co-infection worsens outcomes

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14. PRE-TREATMENT EVALUATION

Mnemonic: "WBCBS + CXR + Pregnancy" (for DS-TB)

1. Detailed history (mental illness, seizures, substance abuse)
2. Weight and height
3. Blood - CBC, Blood sugar (DM screen), Blood urea/creatinine (renal function)
4. Chest X-ray
5. Sputum (baseline)
6. LFT (liver function tests)
7. Urine routine
8. HIV testing (mandatory)
9. Pregnancy test (all women of childbearing age)

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15. NIKSHAY & PROGRAMME SUPPORT

• Nikshay: India's web-based TB notification system (mandatory notification for all TB cases - government and private)
• Nikshay Poshan Yojana: DBT (Direct Benefit Transfer) of ₹500/month to TB patients for nutritional support during treatment
• TB-free India Campaign: NSP target 2017-2025 - eliminate TB by 2025
• ASHA, DOTS providers: Community-level treatment supporters

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MASTER MNEMONIC FOR NTEP

"DOTS SAVES"

• DOTS strategy (5 components: PDADS)
• Objective: 85% cure + 70% detection
• Treatment: Daily FDC (2HRZE/4HRE)
• Screening: Passive + Intensified case finding

• STOP TB (6 components: PAC-EEE)
• Anti-TB drugs: RHZES first-line
• Vulnerable groups: LTBI treatment
• End TB (3 pillars: I-B-I; target eliminate by 2025/2035)
• Surveillance: Nikshay notification (mandatory)

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NLEP - National Leprosy Eradication Programme

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1. LEPROSY - THE DISEASE

Mnemonic: "SAN" = Skin patch + Anesthesia + Nerve thickening

1. Hypopigmented/reddish skin lesion(s) with definite sensory loss
2. Thickened peripheral nerves with loss of sensation ± weakness/paralysis
3. Demonstration of M. leprae in slit-skin smear (acid-fast bacilli)

Tuberculoid (TT) ←→ Borderline TT ←→ Borderline ←→ Borderline LL ←→ Lepromatous (LL)
  High immunity                                                      Low immunity
  Few bacilli (PB)                                              Many bacilli (MB)

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2. EPIDEMIOLOGICAL DETERMINANTS

Agent - M. leprae

• Acid-fast; occurs intracellularly + extracellularly in human host
• Grows in characteristic clumps/bundles called "GLOBI"
• Affinity for Schwann cells and reticuloendothelial cells
• Bacteria load: 2-7 billion per gram of leproma (lepromatous cases)
• NOT grown in artificial medium; grown in 9-banded armadillo and nude mouse
• Specific antigen: Phenolic Glycolipid (PGL-1)

Source of Infection

• Multibacillary cases (LL and BL) = most important source
• Inapparent infections also contribute
• All patients with "active leprosy" must be considered infectious
• Natural infection also found in armadillos, mangabey monkeys, chimpanzees

Portal of EXIT

• Nose = major portal of exit (lepromatous nasal mucosa = millions of bacilli)
• Also through ulcerated/broken skin

Portal of ENTRY

• Nose (respiratory tract) = main portal of entry
• Skin (minor route)

Infectivity

• Highly infectious, but low pathogenicity
• Rendered non-infectious by:
  • Dapsone for ~90 days
  • Rifampicin for 3 weeks (faster)

Host Factors

• Most susceptible: Children (family contacts)
• Immunity: Cell-mediated immunity (CMI) protects → tuberculoid end of spectrum
• Loss of CMI → lepromatous end
• Incubation period: Average 3-5 years (range: 6 months to 20 years; longest of any known bacterial disease)

Mnemonic for Incubation: "Leprosy is Leisurely" = Longest IP = 3-5 yrs average, up to 20 years

Transmission

• Prolonged close contact with untreated MB patient
• Droplet from nose (primary)
• Broken skin (secondary)
• Leprosy is NOT hereditary

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3. CLASSIFICATION

WHO Classification (used in NLEP/programme):

Mnemonic: "PB = 1-5 patches (Poor Bacilli); MB = More than 5 (Many Bacilli)"

Ridley-Jopling Classification (Spectrum):

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4. DIAGNOSIS

Cardinal Signs (minimum 1 needed):

1. Hypopigmented patch with sensory loss
2. Thickened nerve + loss of sensation ± motor deficit
3. AFB in slit-skin smear

Commonly Affected Nerves:

Mnemonic: "ULTRA-P" = Ulnar, Lesser occipital (Greater auricular), Tibial, Radial, Abducent/Facial, Peroneal

Slit-Skin Smear (SSS):

• Site: Active lesion + ear lobe
• "Slit and scrape" method; stained with Ziehl-Neelsen
• Bacterial Index (BI): Measures bacillary load (0 to 6+)
• Morphological Index (MI): % of solid-staining (viable) bacilli - used to assess treatment response

Lepromin Test (Mitsuda Test):

• NOT a diagnostic test (cannot diagnose leprosy)
• Measures cell-mediated immunity (CMI)
• Read at 28 days (Mitsuda reaction - papule/nodule >5 mm = positive)
• Positive in TT, Negative in LL
• Used to classify leprosy and assess prognosis

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5. MDT - MULTI-DRUG THERAPY

Why MDT? Because of:

• Primary and secondary dapsone resistance
• Need to kill persisters
• Reduce treatment duration

MDT Regimens (WHO):

Adults - Multibacillary (MB) Leprosy:

Adults - Paucibacillary (PB) Leprosy:

Children (10-14 years) - MB:

• Rifampicin 450 mg once monthly (supervised)
• Dapsone 50 mg daily (self)
• Clofazimine 150 mg monthly (supervised) + 50 mg alternate days

Children (10-14 years) - PB:

• Rifampicin 450 mg once monthly (supervised)
• Dapsone 50 mg daily (self)

Mnemonic for MB: "RDC" = Rifampicin + Dapsone + Clofazimine Mnemonic for PB: "RD" = Rifampicin + Dapsone

Duration:

Mnemonic: "MB = 12/18; PB = 6/9" (double the time as cushion for defaults)

Key Drug Points:

• Rifampicin: Most potent bactericidal; renders patient non-infectious within 3 weeks
• Dapsone: Bacteriostatic; cheapest; resistance can develop (hence MDT)
• Clofazimine: Bactericidal + anti-inflammatory (reduces reactions); causes skin discolouration (reddish-brown) - if unacceptable, substitute ethionamide/protionamide

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6. LEPROSY REACTIONS

Mnemonic: "T1 = Type 1 = Tuberculoid (Reversal Reaction); T2 = Type 2 = Two-system (ENL)"

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7. DISABILITY GRADING

Mnemonic: "0-1-2 = Zero, Look, Lost"

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8. HISTORY OF NLEP

Mnemonic: "Control → Eradication → World Bank → Integrated"

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9. NLEP - PROGRAMME DETAILS

Goal:

5 Components of NLEP:

Mnemonic: "DICIM" = Decentralized, Integration, Capacity, IEC, Monitoring

1. Decentralized integrated leprosy services through general health care system
2. Integration - capacity building of general health services staff
3. Capacity building of all functionaries
4. Intensified IEC (Information, Education, Communication)
5. Monitoring - Prevention of Disability + Medical Rehabilitation (DPMR) + intensified supervision

Key Indicators:

• ANCDR (Annual New Case Detection Rate) - main monitoring indicator (replaced prevalence)
• Treatment Completion Rate - calculated by states yearly
• PR - Prevalence Rate (elimination target: <1/10,000)

Status of India (current data from textbook):

• 34 states/UTs achieved elimination (PR <1/10,000)
• Chhattisgarh and Dadra & Nagar Haveli: PR of 2-5/10,000 (pending)
• Bihar, Goa, Chandigarh, Odisha: achieved elimination but PR slipped back >1/1,000
• 209 high-endemic districts identified for special action

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10. MAJOR INITIATIVES UNDER NLEP

ASHA Involvement:

DPMR - Disability Prevention & Medical Rehabilitation:

• Dressing materials, ulcer kits, supportive medicines
• Micro-cellular rubber (MCR) footwear for insensitive feet
• 83 centres (41 NGOs + 42 Govt Medical Colleges) for reconstructive surgery
• Rs. 5,000/- incentive for BPL patients undergoing reconstructive surgery
• Rs. 8,000/- for ALL patients undergoing major reconstructive surgery (irrespective of financial status)
• 115 RCS centres (61 Government + 54 NGO) as of January 2017

Sparsh Leprosy Awareness Campaign:

• Launched: 2017
• Through Gram Sabhas, Panchayat, Village Health and Sanitation Committees
• Aim: Generate awareness, reduce stigma, improve self-reporting
• Covered 60% of total villages across India

SET Scheme (Survey, Education, Treatment):

• NGOs involved in: disability prevention, ulcer care, IEC, referral for RCS, research, rehabilitation

Research Institutions:

• Central JALMA Institute of Leprosy - Agra
• Central Leprosy Teaching and Training Institute - Chingleput (Chennai)
• Regional Training and Referral Institutes at Aska (Odisha), Raipur (Chhattisgarh), Gouripur (West Bengal)

International Support:

• ILEP (International Federation of Anti-Leprosy Associations) - 10 agencies in India
• WHO technical support

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11. CONTROL MEASURES SUMMARY

Medical Measures (10):

Mnemonic: "EECM-SIDRH" or just remember these 10:

1. Estimation of the problem (surveys)
2. Early case detection (passive + active)
3. Chemotherapy = MDT
4. Monitoring
5. Surveillance
6. Immunoprophylaxis (BCG - partial protection ~50%)
7. Chemoprophylaxis (dapsone for contacts in some settings)
8. Deformity prevention (DPMR)
9. Rehabilitation
10. Health education

3 Goals of Leprosy Control:

1. Interrupt transmission → reduce incidence
2. Treat patients → cure + rehabilitation
3. Prevent deformities

BCG Vaccination:

• Gives partial protection (~50%) against leprosy
• Correlation: positive lepromin test after BCG = protective immunity
• Countries with good BCG coverage show lower leprosy rates

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MASTER EXAM MNEMONICS SUMMARY

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Poliomyelitis & National Programme (Pulse Polio / UIP)

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1. POLIOMYELITIS - THE DISEASE

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2. EPIDEMIOLOGICAL DETERMINANTS

Agent - Poliovirus

Mnemonic for types: "1 Paralyses, 2 Perished, 3 VAPP" = Type1 most paralytic, Type2 eradicated, Type3 causes most VAPP

Source of Infection

• Humans (patients + inapparent/subclinical cases)
• Inapparent infections vastly outnumber clinical cases

Portal of Exit

• Faeces (primary - virus shed in stools for weeks)
• Pharyngeal secretions (early, short-lived)

Mode of Transmission

• Faeco-oral route (main) - contaminated water/food
• Droplet/contact (oral-pharyngeal secretions, early)

"Polio = Poop to Mouth" - faeco-oral is dominant

Portal of Entry

• Oropharynx and intestinal tract

Incubation Period

• Range: 3-35 days
• Typically 7-14 days
• For paralytic disease: 7-21 days

Host Factors

• Most susceptible: Children under 5 years (hence "Infantile Paralysis")
• Immunity: Type-specific and life-long after infection
• Risk factors for paralysis: Tonsillectomy, IM injections during incubation ("provocation paralysis"), pregnancy, physical exertion, immunodeficiency

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3. CLINICAL SPECTRUM

Mnemonic: "AMAB" = Asymptomatic → Minor → Abortive → Big (Major)

Types of Paralytic Polio:

1. Spinal (most common) - anterior horn cells affected; flaccid, asymmetric paralysis of limbs; lower limbs > upper
2. Bulbar - cranial nerve nuclei affected; respiratory/swallowing muscles → life-threatening
3. Bulbospinal - combined

Hallmarks of Paralytic Polio:

• Asymmetric flaccid paralysis
• Fever at onset
• Rapid onset (24-48 hours)
• No sensory loss
• Proximal muscles > distal
• Residual paralysis at 60 days = diagnostic criterion

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4. DIAGNOSIS

Case Definition (WHO - for AFP surveillance):

AFP Surveillance - 4 Steps:

Mnemonic: "FILM" = Find, Isolate (lab), Locate (map), Move (stool samples)

1. Find and report AFP cases in children <15 years
2. Move stool samples - 2 specimens, 24-48 hours apart, within 48 hours of onset, stored at 4-8°C, reach lab within 72 hours
3. Isolate poliovirus in lab; distinguish WPV from vaccine virus
4. Map the virus - genetic typing to trace geographic origin

AFP Surveillance Indicators:

• Non-Polio AFP Rate (NP-AFP): Should be ≥2 per 1,00,000 children under 15 (indicates sensitive surveillance)
• Stool adequacy: 2 adequate specimens from ≥80% of AFP cases
• Follow-up all AFP cases at 60 days to check residual paralysis

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5. VACCINES - COMPARISON (HIGH YIELD)

OPV vs IPV - The Classic Comparison:

Mnemonic: "OPV = Oral Gut-immunity, Herd immunity; IPV = Injected blood-only immunity"

OPV Details:

• Composition: trivalent (tOPV) - types 1, 2, 3; now replaced by bOPV (types 1 and 3 only) after 2016 switch
• Dose: 2 drops orally
• Schedule (India): Birth + 6, 10, 14 weeks (as part of UIP) + booster at 16-24 months
• Storage: 2-8°C; freezing enhances potency (unlike most vaccines)
• Contraindications: Immunodeficiency states (HIV, steroid therapy)
• VAPP: Most commonly from Type 3 (Sabin 3) - 60% of cases; occurs in both recipients and unimmunized contacts

IPV Details:

• Composition: Inactivated types 1, 2, 3 (D-antigen: 40 + 8 + 32 units)
• Route: IM or fractional IPV (fIPV) - 0.1 ml intradermal (India)
• India schedule: fIPV at 6 weeks and 14 weeks
• Introduced in India: 30 November 2015 (as part of Endgame strategy)
• Advantages: Safe in immunocompromised, pregnancy, elderly
• Disadvantage: No intestinal/mucosal immunity; cannot stop gut replication/shedding

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6. VACCINE-DERIVED POLIOVIRUS (VDPV)

• OPV virus can undergo genetic changes during replication
• In communities with low vaccination coverage, mutant attenuated virus can become neurovirulent = VDPV
• VDPV paralysis is clinically indistinguishable from WPV paralysis
• Diagnosed by: rRT-PCR (real-time reverse transcription PCR)

Types of VDPV:

Mnemonic: "CIA" = Circulating, Immunodeficiency, Ambiguous

• Most cVDPV and VAPP = Type 2 (was in tOPV) → reason for tOPV → bOPV switch

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7. GLOBAL ERADICATION TIMELINE

Mnemonic: "1988 - 125 countries; 1999 - Type 2 gone; 2012 - Type 3 gone; 2014 - India free; 2015 - Type 2 declared eradicated"

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8. POLIO ERADICATION ENDGAME STRATEGIC PLAN 2013-2018

3 Key Steps:

1. Introduce at least 1 dose of IPV into all routine immunization systems by end 2015 (at least 6 months before switch)
2. Switch from tOPV to bOPV in 2016 (synchronized global cessation of OPV type 2 use)
3. Plan for eventual withdrawal of all OPV

• WPV Type 2 absent since 1999
• Risk of VAPP and cVDPV2 from OPV type 2 now outweighs benefits
• 97% of global cVDPV and 40% of global VAPP = due to type 2 component

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9. NATIONAL PROGRAMME - INDIA

A. Universal Immunization Programme (UIP)

• Launched: 1985-86 (as Expanded Programme on Immunization started 1978)
• OPV given as routine immunization: Birth, 6, 10, 14 weeks + booster doses
• Covers all vaccine-preventable diseases under national schedule

B. Pulse Polio Immunization (PPI) Programme

• Launched in India: 1995
• First NIDs (National Immunization Days): 2nd December 1995 and 3rd January 1996

• Additional OPV drops given on fixed days (usually December and January each year)
• From 1999-2000: House-to-house vaccination of missed children added
• NIDs (National Immunization Days): Cover ~172 million children
• SNIDs (Sub-National Immunization Days): Cover ~40-80 million children

C. Strategies for Polio Eradication in India:

Mnemonic: "PULSE CAMP" = Pulse Polio, UIP sustained, Line listing, Surveillance-AFP, Collect stools, Alert (outbreak control), Mopping up, Prevention (follow-up at 60 days)

1. Conduct Pulse Polio Immunization days every year
2. Sustain high levels of routine immunization coverage
3. Monitor OPV coverage at district level and below
4. AFP surveillance - detect all AFP cases (polio + non-polio)
5. Rapid case investigation - collect stool samples for virus isolation
6. Follow-up all AFP cases at 60 days for residual paralysis
7. Outbreak control within 48 hours of notification
8. Mopping Up - door-to-door immunization in high-risk districts

D. Mopping Up:

• Last stage of eradication
• Door-to-door immunization in high-risk districts where WPV known/suspected
• Used to catch children missed during fixed-post campaigns

E. Line Listing of Cases:

• Started: 1989
• Purpose: Check for duplication, track high-risk areas, document age distribution, guide follow-up

F. AFP Reporting:

• Name, age, sex, father's name, complete address
• Vaccination status
• Date of onset of paralysis + date of reporting
• Clinical diagnosis
• Doctor's name and contact

G. Introduction of IPV in India (Endgame Strategy):

• IPV introduced: 30 November 2015
• Given as fractional IPV (fIPV): 0.1 ml intradermal at 6 weeks and 14 weeks
• Reason: Mitigate risk of VDPV type-2 after tOPV withdrawal

H. Key Milestones - India:

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10. MASTER COMPARISON TABLE - OPV vs IPV

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11. HIGH-YIELD EXAM POINTS WITH MNEMONICS

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