Community medicine i

Chapter one:
Principles of Community
Medicine/Community Health
LECTURER: SA‘AD AHMED. ABDIWALI (HO/PH, B. Pharm. MPH CANDIDATE
(DEAN OF PUBLIC HEALTH)

Objectives
• Describe the 4 dimensions of community
medicine
• Understand the curricular requirements for
community medicine

Community Medicine
• Providing medical services in the community
• Understanding community resources
• Health promotion and disease prevention
• Occupational health
• Knowledge of communities
• Care of populations
• Community participation in health care activities

4 Dimensions of Community Medicine
• Paying attention to sociocultural aspects of patient
care
• Coordinating a community‘s health resources in the
care of patients
• Identifying and intervening in a community‘s health
problem
• Assimilating into a community and participating in its
organizations

Definition of community
• A true community in the sociological sense (shared
community sentiment, social institutions)
• A defined neighborhood
• Workers/students in a defined company/school
• Persons registered as potential users of a group
practice/health center
• Users of a defined service or repeated users of the
service

Declaration of Alma Ata
• International Conference on Primary Health
Care, 1978
• Health is a fundamental human right

Community Oriented Primary Care (COPC)
• Primary care practice
• Defined community
• Process
– Defining and characterizing the community
– Describing community health problem
– Modifying health care program to address high-priority
health needs
– Monitoring effectiveness of program modifications

COPC Competencies
• Define and characterize a given population using
secondary data
• Recognize a community health problem using either
subjective or objective data
• Design an intervention to address a recognized
community health problem
• Know which community resources address a
recognized problem

COPC Competencies
• Contribute to an organized community action group
and monitor the group‘s progress
• Determine roles of attending and faculty physicians
in community action groups
• Locate local, state and national databases for
common or chronic disease states
• Exhibit group leadership skills in a multidisciplinary
setting

COPC Curricular Topics
• Clinical epidemiology
• Design and evaluation of outcome studies
• Leadership and group facilitation skill training
• Team skills
• Medical information storage and retrieval systems
• Medical cost analysis
• Health promotion and disease prevention techniques
• Family physician‘s role in the community‘s health
• Population-based medicine

Community Medicine Curriculum
• (1) assessment of risks for abuse, neglect, and family and community violence
• (2) reportable communicable disease
• (3) population epidemiology, and the interpretation of public health statistical
information
• (4) environmental illness and injury
• (5) school health
• (6) disease prevention through immunization strategies
• (7) disaster responsiveness
• (8) community-based disease screening, prevention, health promotion
• (9) factors associated with differential health status among subpopulations,
including racial, geographic, or socioeconomic health disparities, and the role of
family physicians in reducing such gaps

Community Medicine Curriculum
• (10) experience in using community resources appropriately for individual
patients who have unmet medical or social support needs
• (11) structured interaction with the public health system
• (12) occupational medicine including disability determination, employee
health and job-related illness and injury
• (13) experience in community health assessment
• (14) experience in developing programs to address community health
priorities
• (15) community-based health education of children and adults

Participation in health activities in the
community
• Identifying and intervening in the community‘s
health problems

Sociocultural awareness in the care
of patients
• Responding to the particular health issues of
local cultural groups when caring for patients

Understanding and appropriate use of the community‟s
health resources in the care of patients
• Coordinating local community health
resources in the care of patients

Community participation and
assimilation
• Assimilating into the community and its
organizations

19
Chapter: two
SOCIO-ECONOMIC IMPACT ON
THE HEALTH OF THE
COMMUNITY

20
DEFINITION OF HEALTH
The World Health organization defines
health as :
― the state of complete physical, mental,
social and psychological well-being of
the individual… AND not merely the
absence of disease or infirmity. ―

21
BACKGROUND 1
1. The limited ROLE of medicine:
 In early 17th century Europe, the common disease
pattern was similar to ours.
 Vital statistics and prevalence & incidence of
infectious and communicable diseases were
comparable to those in the underdeveloped world.
 The discovery of Penicillin did NOT bring about a
major appreciable change in disease occurrence
or pattern.

22
BACKGROUND 2
2. The spread of epidemics and pandemics such as
cholera, plague, smallpox, scabies, malaria etc.
was common.
3. The socio-economic status of the populations was
very poor with high unemployment and social
deprivation.
4. Personal, food and environmental hygiene were
poor.
5. The nutritional status of the U-fives and the
general population was extremely bad.

23
WHAT WERE THE MAIN FACTORS
WHICH BROUGHT ABOUT THE
CHANGE
IN THE ATTAINMENT OF GOOD
QUALITY HEALTH CARE STATUS
IN THE DEVELOPED WORLD ?

24
A. ENVIRONMENTAL
FACTORS ON HEALTH 1
1. Improvement in the provision of safe water
supply has greatly reduced water-borne,
water-washed and other water related
diseases.
2. The establishment of public & private latrines
and toilets have also contributed to reduction
of disease occurrence and strengthened
prevention of disease.

25
A. ENVIRONMENTAL
FACTORS 2
3. Inadequate shelter was replaced by good,
low cost public housing schemes and
projects.
4. Adequate and proper sewage systems were
installed.
5. Agricultural and poultry farms were given
subsidies to produce good and healthy
products.

26
B. SOCIO-ECONOMIC FACTORS 1
1. Along with the above improvements, the
industrial revolution has brought about
significant changes in the economic
development and social status.
2. Literacy rate has gone up sharply due to
increased educational opportunities.
3. Employment has increased thus significantly
raising household income.

27
B. SOCIO-ECONOMIC FACTORS 2
4. The standard of living has greatly improved and
healthy lifestyle adapted.
5. Nutritious and healthy foods could be afforded by
families thus decreasing malnutrition.
6. Women had more access to educational
opportunities thus improving & enhancing socio-
economic status of the family in particular & the
society in general.
7. Employment of women in the workforce has
increased.

28
THE IMPACT ON HEALTH
STATUS
1. Incidence & prevalence of diseases have decreased
dramatically.
2. Nutritional status has improved drastically.
3. Personal, food & environmental hygiene and sanitation
have greatly improved.
4. Vital statistics have changed for the better as have
other health status indicators ( see below).
5. Social & economic indicators improved (see below).
6. Indicators of social & mental pathology have
decreased (see below).

29
HEALTH STATUS INDICATORS
1. Percentage of low birth weight newborns (less
than 2.5 kg).
2. IMR, U-5 mortality rate.
3. Maternal mortality rate.
4. Crude death rate.
5. Birth rate.
6. Disease-specific morbidity & mortality rates.
7. Life expectancy at birth or at a given age.
8. Population growth.
9. Disability rate.

30
SOCIAL & ECONOMIC
INDICATORS
1. Rate of population increase.
2. Gross National Product (GNP) and Gross
Domestic product (GDP).
3. Adult literacy ( women ? Discuss importance ).
4. Adequate housing ( number of persons per room
).
5. Income distribution.
6. Availability of work.
7. Availability of safe water supply & sanitation.
8. Per capita energy availability.

31
INDICATORS OF SOCIAL &
MENTAL PATHOLOGY
1. Suicide rates.
2. Drug addiction and its extent.
3. Crime rates.
4. Heavy or excessive smoking rates.
5. Alcoholism, Qatism !
6. Obesity; adult malnutrition.
7. Juvenile delinquency.
8. Post traumatic distress syndrome.

32
COMPARE INDICATORS FOR
THESE TWO COUNTRIES AND
DISCUSS
Country A. Country B
1. IMR 37/1000 live births 132/1000
2. CDR 6/1000 20/1000
3. Life Exp. at birth 70 years 47 years
4. Socio-economic status ? Underdeveloped.
5. Major diseases ? Infect.tropical.comm.dis.

33
FACTS 1:
Health problems AND socio-economic problems in the
Third World ARE intimately interlinked.
 People in the underdeveloped countries are trapped in A
VICIOUS cycle of Poverty, Malnutrition, Disease and
despair.
 Most deaths are due to infectious and parasitic diseases.
 Most diarrhoeal diseases are transmitted by human faecal
contamination of soil, food, and water. (lack of access to
dependable safe water supply and adequate sanitary
facilities).
 Malaria, among insect & vector-borne diseases, alone have
a serious adverse socio-economic effect.

34
FACTS 2
 In general, countries with HIGH GNP have a LOW IMR
and a HIGH life expectancy. The opposite is true for
those with LOW GNP.
 In most underdeveloped countries, GNP per capita
ranges from 200 US$ to 1000$ as compared to 5000 to
10,000 US$ in the developed countries.
 The average per capita income is less than 1 US$ in
many African countries and does not grow by no more
than 1% a year.
 There are great inequalities within the underdeveloped
countries with adverse effects on the underprivilegded
poor segments of society.

35
Facts 3
 In most of the underdeveloped countries,
malnutrition and undernutrition affect most
people thus: 1) reducing their energy and
motivation, 2) undermining their performance at
school and at work, 3) reducing their resistance to
disease.
 The average per capita daily energy intake is about
2-2400 kilocalories in the underdeveloped world
compared to over 4000 kilocalories in the

36
FACTS 4
Literacy has a major importance for health.
 It enables people to understand their health problems
and ways of doing something about them.
 It facilitates people’s active involvement in community
health activities.
 Adult literacy rate is roughly 100% in the developed
world while it’s about 30-40% in the underdeveloped
countries with only about 15% among women in the
latter.
 About 40% of children of those who cannot read and
write only complete not more than 4-5 years of primary
education.

37
FACTS 4
On top of all the above problems; the health systems are poorly
organized in the underdeveloped world:
 The majority (2/3s) of the people have no reasonable access
to permanent appropriate healthcare services.
 The vast proportion of resources for health care delivery is
concentrated in big cities and other large urban settlements.
 Worse still, these resources are devoted to expensive,
sophisticated technology serving a small minority of the
population at the expense of primary health care or
community medicine for the majority.
 Deficient planning & management including inadequate
cooperation with other social & economic sectors in
commonplace.

38
FACTS 5
In many underdeveloped countries health manpower poses
several problems:
 May not be appropriately trained for the tasks they are
expected to perform; or not provided with the equipment &
supplies needed.
 Inequality in distribution of health personnel; most are in the
cities and urban centres while rural populations are often
neglected.
 The average doctor/people and nurse/people ratios are
unsatisfactory: 1/17000 and 1/6500 respectively compared
to 1/150 and 1/220.
 In the rural areas the ratio could reach 1:250,000.
 Equitable distribution of health manpower is vital to ensure

Chapter three:
Sexually Transmitted
Infections
Introduction
Background
 Sexually transmitted infections (STI) remain a
public health problem of major significance in most
parts of the world. The incidence of acute STIs is
believed to be high in many countries. Failure to
diagnose and treat STIs at an early stage may result
in serious complications and sequelae, including
infertility, fetal wastage, ectopic pregnancy,
anogenital cancer and premature death, as well as
neonatal and infant infections
The appearance and spread of HIV/AIDS has
focused greater attention on the control of STIs.

• There is strong correlation between the spread of
conventional STIs and HIV transmission, and both
ulcerative and non-ulcerative STIs has been
found to increase the risk of sexual transmission
of HIV.
• The emergence and spread of HIV infection and
AIDS have also complicated the management and
control of some other STIs. For example, owing to
HIV-related immunosuppression, the
management of chancroid has become
increasingly difficult in areas with a high
prevalence of HIV infection

• Antimicrobial resistance of several sexual
transmitted pathogens is increasing, rending some
regimens ineffective. New agents, such as third-
generation cephalosporins and fluoroquionolones,
capable of treating infections with resistant strains,
are available but remain expensive. How ever, their
initial high cost must be weighed against the cost of
inadequate therapy, including complications,
relapse and further transmission of infections.

Rationale for standardized
treatment of STI
• Effective management of STIs is one the
cornerstone of STI control, as it prevents the
development of complications and sequelae,
decreases the spread of those infections in the
community and offers a unique opportunity for
targeted education about HIV prevention
• Appropriate treatment of STIs infection at the first
contact between patients and health care
provider is, therefore, an important public health
measure. In the case of adolescent (10 – 19 yrs-
WHO) patients, there is the potential to influence
future sexual behaviour and treatment-seeking
practices at a critical stage of development.

• It is strongly recommended that countries establish
and use national standardized treatment protocols
for STIs. These can help to ensure that all patients
receive adequate treatment at all levels of health
care services.
• The protocols can also facilitate the training and
supervision of health care providers and can help to
reduce the risk of development of resistance to
antimicrobials. Finally, having a standardized list of
antimicrobial agents can also facilitate drug
procurement

• It is anticipated that the recommendations
contained in this document will help to
develop standardized adapted to local
epidmiological and antimicrobial sensitivity
patterns.
• It is recommended that national guidelines for
effective management of STIs be developed
in close consultation of with local STIs and
public health experts

Case Management
• STI case management is the care of person with an-STI related
syndrome or with positive test for one or more STIs. The components
of case management include:
1. History taking
2. Clinical examination
3. Correct diagnosis
4. Early and effective treatment
5. Advice on sexual behaviour
6. Partner notification and treatment
7. Case reporting and clinical follow-up as appropriate
• Thus, effective case management consists not only of antimicrobial
therapy to obtain cure and reduce infertility, but also comprehensive
consideration and care of the patient‘s reproductive health.

Syndromic Management
• Etiological diagnosis of STIs is problematic for
health settings. It places constrains on their time
and resources, increases cost and reduces access
to treatment. in addition, the sensitivity and
specificity of commercially available tests can vary
significantly, affecting negatively the liability of
laboratory testing for STI diagnosis.
• Where laboratory facilities are available they must
be staffed by suitably qualified personnel with
adequate training to perform technically demanding
procedures, and the establishment of external
quality control must be mandatory.

• Many health care facilities in developing countries lack the
equipments and trained personnel required for etiological
diagnosis of STIs. To overcome this problem, a syndrome-
based approach to the management of STI patient has been
developed and promoted in a large number of countries in
the developing word.
• The syndromic management approach is based on the
identification of consistent group of symptoms and easily
recognized signs (syndromes), and provision of treatment
that will deal with the majority of, or the most serious,
organisms responsible for producing a syndrome.WHO has
developed a flowchart to guide health workers in the

• Syndromic management for urethral discharge in men, and
genital ulcers in men and women, has proved to be both
valid and feasible. It has resulted in adequate treatment of
large numbers of infected people, and is inexpensive, simple
and very cost-effective.
• WHO‘s simplified generic tool includes flowcharts for women
with symptoms of vaginal discharge and/or lower abdominal
pain. While the flowcharts for abdominal pain are quite
satisfactory, those for vaginal discharge has limitations,
particularly in the management of cervical (gonococcal and
chlamydia) infections. In general, but especially in low-
prevalence settings and in adolescent females, endogenous
vaginitis rather than an STI is the main cause of vaginal
discharge.

• Attempts made to increase the sensitivity and specificity of
the vaginal discharge flowchart for the diagnosis of cervical
infection, by introducing an appropriate, situation-specific
risk assessment, has not been successful.
• Some of the risk assessment questions based on
demographics, such as age and martial status, tend to
classify too many adolescents as being at risk of cervical
infections. Therefore, there is a need to identify the main STI
risk factors for adolescents in the local population and tailor
the risk assessment accordingly. For adolescent in particular
it may be preferable to base the risk factor on sexual
behaviour patterns.

Risk factors for STI-related
cervicitis
• The flowcharts currently available for the
management of cervical infections are therefore far
from ideal. Initially it was thought that the finding of
vaginal discharge would be indicative of both
vaginal & cervical infection. However it become
clear that while vaginal discharge is indicative of
the presence of vaginal infection, it is poorly
predictive of cervical infection (gonocaccal or
chlamydia), particularly in adolescent girls
• Some clinical signs seen to be more frequently
associated with the presence of cervical infection.
These are the presence cervical mucopus, cervical
erosions, cervical friability and bleeding between
menses or during cervical intercourse.

• A number of demographic and behavioural risk factors have also been
frequently associated with cervical infections. Some of those are:-
1. Being less than 21 years of age
2. Being unmarried
3. Having more than one partner in the previous 3 months
4. Having partner with STI
5. Recent use of condom by the partner
Such risk factors are, however, usually specific for the population group for
which they have been identified and validated an cannot be easily be
extrapolated to other populations or to other locations.
• Most researchers have suggested that it is important to obtain more
than one demographic risk factor in any particular patient.
• Adding these signs and risk assessment to the vaginal discharge
flowchart does increase its specificity, its positive predictive value,
although the letter remains low specially when flowchart is applied to
populations relatively low rates of infection.

Selection of Drugs
• Antimicrobial resistance of several sexually transmitted
pathogens has been increasing in many parts of the world
and this has rendered some low-cost regimens in-effective.
Recommendations to use more effective drugs frequently
raise concern about cost and possible misuse.
• A two-tier drug policy with the provision of less effective at
the peripheral health care level and most effective and
usually more expensive drugs only at the referral level may
result in an unacceptable rate of treatment failure,
complications and referrals, and may erode confidence in
health services. This approach is not recommend.
• The drugs used for STI treatment in all health care facilities
should have an efficacy of 95%. Criteria for the selection of
drugs are listed in the next slide.

Criteria for the selection of STI
drugs
Drugs selected for treating STI should meet the following criteria:-
• High efficacy (at least 95%)
• Low cost
• Acceptable toxicity and tolerance
• Organism resistance unlikely to develop or likely to be delayed
• Single dose
• Oral administration
• Not contraindicated to pregnant or lactating women
Appropriate drugs should be included in the national essential drug list and
in choosing drugs, consideration should be given to the capabilities and
experience of health personnel

Chapter: 4
Course: Community Medicine
Title: Water and Sanitation
By: Saad Ahmed Abdi

Water
{‫حي‬ ‫شيء‬ ‫كل‬ ‫الماء‬ ‫من‬ ‫وجعلنا‬{

What is water?
• Water is a chemical substance with the
chemical formula H2O. A water molecule
contains one oxygen and two hydrogen
atoms connected by covalent bonds. Water is
a liquid at ambient conditions, but it often co-
exists on Earth with its solid state, ice, and
gaseous state (water vapor or steam).

• Water covers 70.9% of the Earth's surface,
and is vital for all known forms of life. On
Earth, 96.5% of the planet's water is found
mostly in oceans; 1.7% in groundwater;
1.7% in glaciers and the ice caps of
Antarctica and Greenland; a small fraction
in other large water bodies, and 0.001% in
the air as vapor, clouds.
• Only 2.5% of the Earth's water is
freshwater, and 98.8% of that water is in ice
and groundwater. Less than 0.3% of all
freshwater is in rivers, lakes, and the
atmosphere.

What are water uses?
Water is used in :-
• Agriculture
• As a scientific standard
• For drinking
• Washing
• Transportation
• Chemical uses
• Heat exchange
• Fire extinction
• Recreation
• Water industry
• Industrial applications

Water importance for human body
• Water makes up more than two thirds of human
body weight, and without water, we would die in
a few days. The human brain is made up of 95%
water, blood is 82% and lungs 90%.
• The Institute of Medicine (U.S.) recommends
that, on average, men consume 3.0 liters and
women 2.2 liters; pregnant women should
increase intake to 2.4 liters (10 cups) and
breastfeeding women should get 3 liters (12
cups), since an especially large amount of fluid
is lost during nursing.

• Safe drinking water is essential to
humans and other life forms.
Access to safe drinking water has
improved over the last decades in
almost every part of the world, but
approximately one billion people
still lack access to safe water and
over 2.5 billion lack accesses to
adequate sanitation.
• But what happens if the drinking
water is unsafe ???
• You get water borne diseaes !!!


What are waterborne diseases?
• Water-borne diseases
are infectious diseases
spread primarily
through contaminated
water. Though these
diseases are spread
either directly or
through flies or filth,
water is the chief
medium for spread of
these diseases and
hence they are termed
as water-borne
diseases.

• The most common cause of water-borne illness
is bacteria, such as E. coli, cholera and
salmonella, but illness can also be caused by
protozoa (including giardia and
cryptosporidium), viruses (like hepatitis A, polio
and rotavirus) and chemical pollutants.
• These pathogens travel through water sources
and interfuses directly through people handling
food and water. Since these diseases are highly
infectious, extreme care and hygiene should be
maintained by people looking after an infected
patient.

• Diseases from unsafe water and
lack of basic sanitation kill more
people every year than all forms
of violence, including war.
Children are especially
vulnerable, as their bodies aren't
strong enough to fight diarrhea,
dysentery and other illnesses.
• 90% of the 30,000 deaths that
occur every week from unsafe
water and unhygienic living
conditions are of children under
five years old. Many of these
diseases are preventable. 

• It is estimated that improved sanitation
facilities could reduce diarrhea-related
deaths in young children by more than
one-third. If hygiene promotion is added,
such as teaching proper hand washing,
deaths could be reduced by two thirds. It
would also help accelerate economic and
social development in countries where
sanitation is a major cause of lost work
and school days because of illness.

How to disinfect the water if
its contaminated
• Filtration using:
- straining
- Sand filters
- Ceramic filters
• Boiling
• Chemical disinfection ( chlorine)
• Radiological disinfection ( UV rays)

1- Filtration:
Straining
Straining is a simple method of
filtration. Pouring water
through a clean piece of cotton
cloth will remove some of the
suspended silt and solids.
Sand filters
Household filters may be
assembled inside clay, metal
or plastic containers. The
vessels are filled with layers of
sand and gravel and pipe work
arranged to force the water to
flow upwards or downwards
through the filter. >>

<< Ceramic filters
Water passes slowly through a ceramicor ‗candle‘ filter .
2- Boiling:
Boiling is a very effective method of disinfecting
water, but it is energy consuming. The water should
be brought to a ‗rolling‘ boil and held there for between 1
minute at sea level and 3 minutes at high altitudes.
3- Radiological disinfection (UV rays):
Ultra-violet rays from the sun will destroy harmful
organisms present in the water.
4-Chemical disinfection (chlorine):
Many chemicals can disinfect water but the most
commonly-used is chlorine. When used correctly,
chlorine will kill all viruses and bacteria.

Looking after clean water
There is no point in treating water if it
becomes contaminated again
afterwards. The storage and use of
treated water is just as important
as the treatment process.
Water should be stored in clean,
covered containers and kept in a
cool dark place.

Hygiene promotion
The benefit of providing safe drinking water
will be lost if users do not know how they will
benefit. Changing unhygienic behavior is just
as important as the provision of clean
water.

• ‫قال‬ ‫ملسو هيلع هللا ىلص‬ ‫هللا‬ ‫رسول‬ ‫ان‬:‖‫ٌحب‬ ‫نظٌف‬ ،‫الطٌب‬ ‫ٌحب‬ ‫طٌب‬ ‫هللا‬ ‫إن‬
― ‫أفنٌتكم‬ ‫فنظفوا‬ ،‫الجود‬ ‫ٌحب‬ ‫جواد‬ ،‫الكرم‬ ‫ٌحب‬ ‫كرٌم‬ ،‫النظافة‬
• ‫رواه‬ ) ‫دفنها‬ ‫وكفارتها‬ ‫خطٌئة‬ ‫المسجد‬ ً‫ف‬ ‫(البصاق‬ ‫ملسو هيلع هللا ىلص‬ ‫قال‬
‫ومسلم‬ ‫البخارى‬

• Sanitation is the hygienic means of promoting health
through prevention of human contact with the hazards of
wastes. Hazards can be either physical, microbiological,
biological or chemical agents of disease. Wastes that can
cause health problems are human and animal feces, solid
wastes, domestic wastewater (sewage, sullage, greywater),
industrial wastes and agricultural wastes. Hygienic means of
prevention can be by using engineering solutions (e.g.
sewerage and wastewater treatment), simple technologies
(e.g. latrines, septic tanks), or even by personal hygiene
practices (e.g. simple handwashing with soap).

Overview
The World Health Organization states that:
"Sanitation generally refers to the provision of facilities
and services for the safe disposal of human urine
and faeces. Inadequate sanitation is a major cause
of disease world-wide and improving sanitation is
known to have a significant beneficial impact on
health both in households and across communities.
The word 'sanitation' also refers to the maintenance
of hygienic conditions, through services such as
garbage collection and wastewater disposal.

• The term "sanitation" can be applied to a specific
aspect, concept, location or strategy, such as:
• Basic sanitation - refers to the management of human
faeces at the household level. This terminology is the
indicator used to describe the target of the Millennium
Development Goal on sanitation.
• On-site sanitation - the collection and treatment of
waste is done where it is deposited. Examples are the
use of pit latrines and septic tanks.
• Food sanitation - refers to the hygienic measures for
ensuring food safety.

• Environmental sanitation - the control
of environmental factors that form links in
disease transmission. Subsets of this
category are solid waste management,
water and wastewater treatment,
industrial waste treatment and noise and
pollution control.
• Ecological sanitation - an approach
that tries to emulate nature through the
recycling of nutrients and water from
human and animal wastes in a
hygienically safe manner.

COMPONENTS OF
ENVIRNOMENTAL
SANITATION
• WATER SANITATION
• FOOD AND MILK SANITATION
• EXCRETA DISPOSAL
• SEWAGE DISPOSAL
• REFUSE DISPOSAL
• VECTOR AND VERMIN CONTROL
• HOUSING
• AIR SANITATION

FOOD AND MILK SANITATION
• The GOLDEN RULE of food
sanitation is:
―Keep it cold or hot, and keep it
covered‖

FOOD SANITATION
• 3 ENEMIES OF FOOD STORAGE:
–HIGH TEMPERATURE
–HIGH HUMIDITY
–CONTAMINATION BY STRONG ODORS

FOOD BORNE DISEASES
FOOD BORNE
INFECTIONS
BACTERIAL
-Typhoid, Cholera,
Bacillary dysentery,
Salmonella
PARASITIC
-Ascariasis,
Trichinosis,
Amoebiasis

FOOD BORNE DISEASES
FOOD POISONING
OR
INTOXICATION
BACTERIAL
-Staphylococcus
-Streptococcus
PLANT OR
ANIMAL
•Mushroom
•Mussels
•Fish
•Herbs
CHEMICAL
•DDT, Lead,
• Mercury, Cadmium

MILK SANITATION
• STERILIZATION- The application of high
temperature for the purpose of destroying all
types of microorganisms.
• PASTEURIZATION- The application of
heat to milk for the purpose of
destroying pathogenic microorganisms
with minimum injury to the substance

MILK SANITATION
• TYPES OF PASTEURIZATION:
– HOLDING OR VAT PASTEURIZATION: 142—
143 F FOR 30 MINS.
– HIGH TEMPERATURE, SHORT TIME [HTST]-
160-162 F FOR 15 MINS.
– FLASH PASTEURIZATION- 190 F FOR FEW
SECONDS.

EXCRETA DISPOSAL
• METHODS :
1. WITH WATER CARRIAGE
2. WITHOUT WATER CARRIAGE

EXCRETA DISPOSAL
1. WITHOUT WATER CARRIAGE
– CAT-HOLE
– SANITARY PIT PRIVY
– CHEMICAL TOILET
– OVERHUNG LATRINE -‖POUR-FLUSH‖
2. WITH WATER CARRIAGE
-WATER SEALED
SEPTIC TOILET/AQUA PRIVY

EXCRETA DISPOSAL
• CHARACTERISTICS OF ADEQUATE EXCRETA
DISPOSAL FACILITIES FOR RURAL AREAS.
– SIMPLE, CHEAP AND EASY TO CONSTRUCT
– EASY TO MAINTAIN
– AFFORDS EASY PROTECTION AGAINST THE
ELEMENTS AND PROVIDE DESIRED PRIVACY
– ACCEPTABLE TO THE USERS

REFUSE/WASTE DISPOSAL
• REFUSE IS A GENERAL TERM APPLIED
TO SOLID AND SEMI SOLID WASTE
MATERIALS OTHER THAN HUMAN
EXCRETA

REFUSE DISPOSAL
• PUBLIC HEALTH REASONS FOR PROPER
DISPOSAL OF WASTES
– BREEDING PLACE FOR INSECTS AND RATS
– GIVES OUT FOUL SMELL
– ―EYE SORE‖
– FIRE HAZARD

• TYPES OF REFUSE
– GARBAGE: LEFT-OVER VEGETABLES,
ANIMAL AND FISH MATERIAL FROM
KITCHENS AND FOOD ESTABLISHMENTS.
– RUBBISH: WASTE MATERIAL SUCH AS
BOTTLES, BROKEN GLASS, TIN CANS,
WASTE PAPERS, DISCARDED
PORCELAINWARE, PIECES OF METAL,
WRAPPING PAPERS …ETC.

• TYPE OF REFUSE:.. Con’t..
– ASHES: LEFT-OVER FROM BURNING OF
WOOD AND COAL.
– DEAD ANIMALS/ CARCASSES
– STABLE MANURE
– STREET SWEEPING: DUST, MANURE,
LEAVES, CIGARETTE BUTTS, WASTE
PAPER AND OTHER MATERIALS THAT
ARE SWEPT FROM THE STREETS

• TYPES OF REFUSE ..con’t..
– NIGHT SOIL: HUMAN WASTE WRAPPED
AND THROWN INTO SIDEWALKS AND
STREETS
– YARD CUTTINGS: LEAVES, BRANCHES,
GRASS

• CHARACTERISTICS OF CONTAINERS
– SMALL ENOUGH TO BE EASILY CARRIED
– SUFFICIENT IN NUMBER
– PROVIDED WITH TIGHT-FITTING COVERS
– MADE OF STURDY MATERIAL
– STEADY
– PLACED IN AN ACCESSIBLE LOCATION

• COMMUNITY REFUSE DISPOSAL
METHODS:
– DUMPING ON LAND
– SANITARY LANDFILL
– COMPOSTING
– INCINERATION

• REFUSE DISPOSAL METHODS FOR
HOUSEHOLDS
– BURIAL
– BURNING
– FEEDING TO ANIMALS
– COMPOSTING
– GRINDING AND DISPOSAL TO SEWER

• REFUSE COLLECTION
1. FREQUENT COLLECTION OF REFUSE,
SPECIALLY GARBAGE, IS
NECESSARY FOR GOOD SANITATION
2. A LONGER INTERVAL BETWEEN
COLLECTION CREATES PROBLEM OF
STORAGE AND FOUL ODOR FOR THE
HOMEOWNER

• REFUSE COLLECTION:
3. It is necessary to cover the refuse in the
vehicles during transportation to final
disposal sites to prevent flies, minimize
odors or remove traveling ―eye sores‖.
4. It is important to have adequate and
properly maintained collection carts,
trucks and other vehicles to eliminate
collection delays and complaints from
residents.

• REFUSE COLLECTIONN…con’t..
5. THE ROUTE TO THE FINAL DISPOSAL
SHOULD BE AS DIRECT AS POSSIBLE
FROM THE POINT OF ORIGIN. It should
preferably not pass busy streets.
6. IT IS PREFERRABLE TO HAVE
COLLECTION DONE AT NIGHT

VERMIN CONTROL
[RODENT AND INSECTS]
• TYPES
–PHYSICAL OR MECHANICAL
–CHEMICAL
–ENVIRONMENTAL
–EDUCATIONAL

HOUSING SANITATION
• CHARACTERISTICS OF AN
ACCEPTABLE HOUSE
– ADEQUATE SPACE
– ADEQUATE LIGHTING
– ADEQUATE WATER SUPPLY: 15-20
GALLONS PER CAPITA PER DAY
…..CONT….

HOUSING SANITATION
• CHARACTERISTICS OF AN
ACCEPTABLE HOUSE…[cont]…
– NOISE: SHOULD NOT BE MORE THAN 30
DECIBELS
– ADEQUATE HEAT AND VENTILATION
– EQUIPPED WITH SANITARY TOILET, FOOD
STORAGE AND PROPER REFUSE
DISPOSAL

IN EMERGENCY SITUATIONS
• SANITARY REQUIREMENTS:
– LATRINE
» __ONE /FAMILY
» ----MIN. 1 SEAT/20 PERSONS
» --- 50 METERS AWAY FROM HOUSES
- WASTE DISPOSAL
- ONE COMMUNAL PIT/500 PERSONS [2X5X2 M]
– SOAP
» 250G/PERSON/MO

IN EMERGENCY SITUATIONS
• OTHER REQUIREMENTS… cont…
– SHELTER
• INDIVIDUAL: 4 SQ.M./PERSON
• COLLECTIVE: 30 SQ,M,/PERSON [INCLUDING
SHELTER, SANITATION SERVICES … ETC]

Who‟s job is it?
• Employee training
should include
the basics of
sanitation.
• Training requires
understanding
and support from
management.
Sanitation is everyone’s responsibility!

ENVIRONMENTAL
SANITATION
SAMPLE QUESTIONS
• THE MOST COMMON AND MOST
PRACTICAL DISINFECTING AGENT FOR
DRINKING WATER:
A. OZONE
B. SILVER
C. UV RAYS
D. CHLORINE

• THE MOST PREFERRED GARBAGE
DISPOSAL SYSTEM IN THE S/LAND:
A. BURRYING
B. SANITARY LAND FILL
C. BURNING
D. INCINERATION

If u’ve any
question…. Plz

Chapter: 5
DISEASE
PREVENTION & CONTROL
Course: Community Medicine I

OBJECTIVE
To reduce incidence, prevalence &
consequences of disease
Community participation,
Political support &
Intersectoral co-ordination

• Although effective control requires
knowledge of multifactorial causation
ESSENTIAL or WEAKEST link – may be
sufficient for disease control
• Eg., cholera epidemic in London -
WATERPUMP

Controlling reservoir
Interruption of transmission
Susceptible host

At reservoir level
1. Early diagnosis
 1st step in control
 USE
Treatment,
epidemiological investigations,
descriptive epidemiology,
institution of control measures

2. Notification
 Enables early detection of outbreaks
 1st health info sub-system to be
established
 Made by physician, head of the family
or lay people (anyone)
 Cholera Plague & yellow fever (1983)
 under WHO surveillance

3. Epidemiological investigations FOR
 Identification of source of infection
 Factors influencing its spread in
community
 Character of agent, reservoir, vectors,
vehicles and susceptible host
populations, geographical, climatic,
social, cultural, behavioral patterns

4. Isolation
• separation, for a period of
communicability of infected animals or
persons from others in such places &
under such conditions, as to prevent or
limit direct or indirect transmission of
infectious agent from those infected to
those who are susceptible, or who may
spread the agent to others.

• OBJECTIVE- to prevent transfer of
infection
• Types
 standard
Strict
Protective
High security
• Oldest CD control measure

Isolation by ring immunization
• Encircling infected persons with a barrier of
immune persons
 Eradication small pox worldwide(60&70s)
 Measles N. America
INEFFECTIVE
 large component of subclinical infection
Eg. Polio Hepatitis A Typhoid Fever
 Highly infectious disease before diagnosis
Eg. mumps

• Replaced by surveillance
o Pertusis-4 wks
o TB-3 wks after chemotherapy
o Hepatitis A-3 wks
o Polio-2 wk adult 6 wk ped.
o Mumps-till swelling subsides
o Shigellosis, salmonellosis-3 conseq. –ve
stool cult.
o Chickenpox 6days after rash appears
o Influenza-3 days after onset
o Measles 3rd day of rash
o Cholera, diphtheria-until 48hrs of
antibiotics
o Meningitis(meningo&streptococcal)-until
6hs of antibiotics

5. Treatment
• AIM – to kill infectious agent when it is still
in reservoir i.e., before dissemination
• RESULT – reduced communicability of
disease, less duration of disease, prevents
development of secondary cases
• NO disease has ever been prevented through
treatment yyyyyyyyyyyyyyyyyyyyyyyessss

6. Quarantine
“ limitation of freedom of movement of such
well persons or domestic animals exposed
to CD for a period of time not longer than
the longest usual incubation period of
disease in such manner as to prevent
effective contact with those not so
exposed”
• Absolute, Modified or segregation
• Replaced by active surveillance

Interruption of transmission
• May be by changing man’s environment
Eg. Water treatment for water borne diseases,
Clean practices for food borne diseases,
Vector control

The susceptible host
1. Active Immunization
• most powerful & cost effective method.
• Strengthens host defenses
• control of some ID solely based on active immunization e.g., polio,
tetanus, diphtheria& measles
• Routine-during infancy & early childhood
• special-high-risk groups or
• specific geographic area
• e.g., cholera,
plague, typhoid,
influenza, yellow fever

• No vaccine for every ID & not 100% effective
• Immunization augments herd immunity-
disease difficulty to spread.
• Infinite number of immunization schedules.
• Good schedule=>
• Epidemiologically relevant,
• Immunologically effective,
• Operationally feasible,
• Socially acceptable.

2. Passive immunization
• short term immunity
• limited value in mass control
• Preparations
• Normal human Ig
• Specific human Ig
• IG—HepA, HepB, Hep non-A non-B, Rubella,
Varicella-zoster, Measles, Rabies, Tetanus, Rh
isoimmunization
• Anti sera or anti toxins
• Diphtheria Tetanus Gas gangrene Rabies
Botulism

3.Combined passive and active
immunization
• e.g., tetanus diphtheria rabies
• Ig should not be given within 3weeks
before or until 2wks after administration of
live attenuated vaccines
• exception hepB vaccine and ig

4. Chemoprophylaxis
• Causal – complete prevention of infection by
early elimination of invading or causal agent
• Clinical – prevention of clinical symptoms
• Indications
Cholera, conjunctivitis, diphtheria, influenza,
malaria, meningitis, plague(pneumonic)

5. Non-specific measures
• Improvement in quality of life
• Legislative measures
• Community involvement
• Played a major role in decline of TB, Cholera,
Leprosy and child mortality in industrialized
nations

obstacles
• Scarcity of funds
• Lack of effective health infrastructure, trained
personnel, supplies, labs, equipment
• Public awareness needed for investigation &
control
• Human behaviour (health education)
• Integration of CD control with PHCare

SURVEILLANCE
• Continuous scrutiny of all aspects of
occurrence and spread of disease that are
pertinent to effective control
• Follows control measures
• Objective : Prevention

individual
• Infected people
Local
population
• Eg., malaria
national
• After disease is eradicated
• Eg., smallpox
international
• Imp. Diseases (malaria, flu ,polio
etc)
• Timely warnings

It includes
Passive reporting of cases
Lab confirmation of presumptive diagnosis
Finding source of infection & routes of
transmission
Identification of all cases, susceptible
contacts & people at risk
Serological surveillance (identify patterns of
present & past infection)

Evaluation of effectiveness of control
measures
Identify reasons for failures if not successful
Then modify existing measures & continue
evaluation

chapter 6
Introduction to
Environmental Health
Community Medicine I

145
Contents
• Importance of environmental health
• Water purification:
– Small quantity
– Large quantity

146
Role of Environment in Health
• Health of man depends on the
interaction between Agent, Host and
Environment – Epidemiological triad

147
Epidemiological triad
Environment
AgentHost
Disease

148
Role of Environment in Health
• Physical environment includes air,
water, soil, housing etc.
• Biological environment includes plants,
animals, insects, bacteria etc.
• Social environment includes customs,
culture, habits, occupation etc.

149
Environment and disease
• Many of the diseases in man are caused by
adverse(‫)وخيم‬ environmental factors like
– Water pollution, air pollution, soil pollution, poor housing,
insect vectors, animal reservoirs etc.
• Due to industrialization and urbanization
environmental pollution has increased, resulting in
increased morbidity

150
Environmental sanitation
• Environmental sanitation(‫)تطهير‬ is not merely
sanitary disposal of excreta
• It means – clean home, clean farm , clean business,
clean neighborhood and clean community
• The purpose of environmental health is to create
and maintain conditions that will promote health and
prevent disease

152
Water
• Many diseases occurring in man are due to
lack of safe drinking water
• Common water-borne diseases are:
– Viral hepatitis E&A, Polio, diarrhea, typhoid,
cholera, amoebiasis etc.
• Providing safe drinking water is very
important to prevent diseases in man

153
Sources of water supply
• Rain
• Surface water
– Reservoirs, Ponds, Sea (after desalination)
– Rivers
• Ground water
– Shallow well
– Deep well – Nahr project of Libya

154
Purification of water
‫الماء‬ ‫تنقية‬
• Purification in small scale (small
quantity) – e.g. in a house
– Boiling, Filtration, Chemical (chlorine
tablets, bleaching powder)
• Purification of water in large scale
(large quantity)
– Purification of water for supplying to a city
is different from purification on a
small scale

155
Purification of water on a large
scale
• There are two methods of purification
– Slow sand filtration
– Rapid sand filtration

156
Slow sand filtration
• There are 3 steps
1. Storage
2. Filtration
3. Chlorination

157
Storage
• Water is first stored in large tanks for about 10 days
• This will result in impurities settling (‫)رسوب‬ down
• Some organic material will be oxidized
• A great decrease (90%) in the number of bacteria
occurs in the water

158
Filtration
• Large Sand(‫)الرمل‬ filters are used to filter
water
• The sand filter consists of sand of different
sizes about 1-1.5 mts in thickness
• When water flows through the sand it gets
filtered

159
Section of sand filter Impure
water
Pure
water

160
Rapid Sand filtration
• There are three steps in rapid sand filtration
1. Mixing with Alum
2. Filtration
3. Chlorination

161
Rapid sand filtration
• Mixing with Alum
– In rapid filtration method water is Not stored
– Water is mixed with Alum, which will combine with the
impurities (‫الشائبة‬) and form big particles(‫جسيم‬ )
– The particles of Alum will settle down with the impurities
and are removed
– The clear water is filtered using rapid sand filter

162
Disinfection
• The last step in water purification is
disinfection
• Destroys most of the infectious agents in the
water
• Chlorination is the most commonly used
method

163
Chlorination
• First the amount of chlorine required to
destroy all microbes and organic matter is
calculated. It is the ‗chlorine demand‘ of
water
• Then chlorine (gas) is added till free chlorine
appears in water
• Wait for 1 hour for the chlorine to kill all the
bacteria
• However some viruses, cysts are not
destroyed

164
Residual chlorine
• 0.5mg of chlorine per liter of water is added
extra to protect against contamination during
distribution of water
• This is called ‗residual chlorine‘

165
Purification of water on small
scale
• Boiling
– Water must be boiled for 5-10minutes
– Care must be taken to prevent contamination
later

166
Chlorination
• Small quantities of water may be disinfected
with chlorine tablet
– 0.5g for 20L
• Bleaching powder can be used to disinfect
wells
– 2.5gm for 1000L

167
Summary
• Environmental sanitation is important to prevent
disease
• Water is an important source of infection
• Safe drinking water is important to prevent diseases
• Water can be purified in small quantities at home by
boiling, chlorination

168
Summary
• Water purification on large scale is done by
2 methods
1. Slow filtration method – Storage, Filtration and
Chlorination
2. Rapid filtration method – Mixing with Alum,
Filtration and Chlorination

Chapter 7
Health Education

171
Contents
• Definition of Health education
• Principles of Health education
• Methods of Health education
• Audiovisual aids

172
Health education
• Health education is an essential(‫)جوهري‬ tool of
community medicine
• Many health problems are due to the lack of
knowledge regarding health among the people
• Health education is a process which produces
changes in the health practices of people
• Health education about common diseases is an
essential component of Primary Health Care

173
Definition(s) of Health Education
• The process by which individuals and groups
of people learn to behave in a manner
conducive to the promotion, maintenance or
restoration of health.
• Health education is the part of health care
that is concerned with promoting healthy
behavior

174
Aims of health education
1. To ensure that health is valued as an asset
of the country
2. To equip people with skills, knowledge and
attitudes to solve their own health problems
3. To promote the development and proper
use of health services

175
Areas of Health Education• Human Biology
• Nutrition
• Hygiene
• Mother and Child health
• Prevention of Communicable diseases
• Prevention of Accidents
• Use of Health Services
• Mental Health

176
Principles of Health Education
• To be effective Health education should be
imparted following certain principles
• Merely talking about health will not lead to
behavior change
• The basic aim of Health education is to
produce behavior change for better health

177
Principles of Health Education
• Interest
• Participation
• Comprehension
• Communication
• Motivation
• Reinforcement
• Learning by doing
• Good Human relations

178
Interest
• People will listen to and learn only things that
they are interested in
• Health educators should find out the health
needs of the people
• And then give information to satisfy those
needs

179
Participation
• Participation is one of the most important
principles of Health Education.
• Participation will lead to active learning, which
is more effective that passive learning
• Group discussion, panel discussion,
workshop are examples of active learning

180
Comprehension
• Health education to be effective the teacher
should know the level of education and
literacy of the audience
• Health education should be within the mental
capacity of the audience

181
Communication
• Communication is the process by which the
health information is transferred to the target
audience.
• The language and words used should be
simple and understandable to the audience

182
Motivation
• Stimulation or awakening of the desire to
learn is called motivation
• Some of the motives are – praise, reward and
punishment
• The health educator should try to stimulate
the desire to learn

183
Reinforcement
• Repeating the health message is important
for learning
• The health message should be given
repeatedly

184
Learning by doing
• Learning should be active and not passive
• People should learn by doing

185
Good Human relations• People relate the health message with the
person giving the message
• So the Health educator must be kind and
sympathetic
• People should consider him/her as their
friend
• So good human relations is very important
for health education

186
Stages in Education
1. Awareness
2. Motivation
1. Interest
2. Evaluation
3. Decision-making
3. Action, adoption or acceptance

187
Stages in Education
• In the first stage the person become aware about
the health problem and its solutions
• Then the person becomes interested in it and learns
more about and evaluates it oneself or by asking
friends or relatives
• Based on the evaluation he will take a decision to
accept it or reject it
• Once he decides to accept it he will adopt the new
healthy lifestyle

188
Audiovisual aids
• For effective Health Education merely talking
is not enough
• Some audiovisual aid has to be used to
convey the message in a more effective way
• There are many Audiovisual aids to assist
health education

189
Audiovisual aids
• Audiovisual aids can be classified into
– Auditory aids
• Radio
• Tape recorder
• Microphones/Amplifier/Speaker or earphones
– Visual aids
• Posters
• Black board/White board
• Flannel graph

190
Audiovisual aids (AV aids)
• Slides
• Films (silent)
• Overhead Projector
– Combined AV aids
• Television
• Films/Videos
• LCD projector
• Audio visual aids are to assist the health
educator and not replace him

191
Methods of Health education
• Health education can be done at 3 levels
– Individual
– Group
– General Public

192
Individual level
• Doctors, nurses and other health
professionals who come in contact with
patients can provide health education at
individual level
– Cardiac patient can be given health education
about healthy diet, exercise etc.
– A pregnant lady can be given health education
about diet, child care etc.

193
Individual level
• The advantage of this method is that the
person gets full attention and he can ask
questions, clear doubts and discuss very
personal or intimate health topics
• The main disadvantage is that the number of
people to whom we can provide such health
education will be very small

194
Group health education
• In this method health education is given to a
group of people
• Mothers, school children, patients, industrial
workers
• Choice of the topic of health education must
be selected with care to make sure that it is of
interest to the group

195
Group health education
• Group health education must not be passive
in which the health educator alone talks
• There should be active participation by the
group members
• The health educator must allow the group
members to ask questions and give
suggestions

196
Methods of group education
• Methods used for group education are:
– Group discussion
– Panel discussion
– Symposium
– Workshop
– Role playing

197
Group discussion
• Group discussion is a very effective method
of health education
• The size of the group should between 2-20
• The group should have a leader who will start
the discussion, keep the discussion on the
topic, encourage all members to participate,
prevent any individual from dominating the
discussion

198
Group discussion• There should be a ―recorder‖ who will note the
points being discussed and prepare a final
report
• The advantage of group discussion is that every
member of the group gets a chance to put his
viewpoint and the entire group will accept the
decisions of the group
• Disadvantage is that some members may
dominate the discussion or they may stray from
the main point and discuss irrelevant things

199
Panel discussion
• In this a panel of speakers (4-8) will
discuss the topic of interest before an
audience
• The chairman will open the discussion,
mange and finally conclude the discussion
• The speakers will talk briefly about the
topic
• The audience can ask questions, give
suggestions, present their problems and
the speakers will respond to it

200
Symposium
• Is a series of lectures by experts on a topic
• The audience can ask questions after the
presentation

201
Role playing
• A small drama is enacted by a group showing
a health situation of importance
– Antenatal visit, use of oral rehydration solution
• The role is enacted before a small group of
people (about 25 members)
• After the role play there is a discussion during
the audience can clear their doubts

202
Health education to General
Public
• It is done through mass media.
– Television, radio, newspaper, posters etc.
• It is the best way of conveying information to
a large population
• However it is not effective in changing human
behavior

203
Barriers of communication
• Health education is basically communication
between the health educator and the target
audience
• For effective health education there should be
good communication
• If communication is not good health
education will be a failure

204
Barriers of communication
• Physiological – difficulties in hearing
• Psychological – emotional disturbance
• Environmental – noise, invisibility
• Cultural – illiteracy, social class difference,
gender differences

205
Summary
• Health education is an important part of Community
Medicine
• Health education should be given based on the
principles of learning
• There are different methods of giving health
education
• Most effective learning is when the health education
is active

Chapter 8
Health
Indicators

Health Indicators
• Health indicators are used to measure health
of a community
– Health indicators can be used to compare health
of two communities
– It can be used to assess the health needs of a
community
– It is useful for monitoring and evaluation of health
programmes

Qualities of an „indicator‟
• Validity – The indicator should measure what
it is supposed to measure
• Reliability – It should give the same value
when measured by different people
• Sensitivity – It should show the changes in
the situation

Health indicators
• Mortality indicators
• Morbidity indicators
• Disability rates
• Nutritional status indicators
• Health care delivery indicators
• Socio-economic indicators
• Indicators of quality of life

Mortality indicators
• Crude death rate
• Specific death rate
• Case fatality rate
• Expectation of life
• Infant mortality rate
• Maternal mortality rate

Crude death rate
• ‗is the number of deaths (from all causes) per
1000 estimated mid-year population in one
year, in a given place‘Number of deaths during a year
Mid-year population
X 1000

Specific death rate
• Is the death rate due to a specific disease, or
in a specific age or sex group etc.
• Specific death rate due to TuberculosisNumber of deaths due to
Tuberculosis during a year
Mid-year population
X 1000

Case fatality rate
• It is the number of people dying due to a
specific disease.
• It shows the severity of the disease
Number of deaths due to a disease
Total number of cases due to the
disease
X 100
%

Infant Mortality Rate (IMR)
• Number of infant deaths in a year per 1000
live births
Number of deaths of children less
than 1 year of age in a year
Number of live births in the same
year
X 1000

Measurements of Morbidity
• Incidence
• Prevalence

Incidence
• There are 500 new cases of Hepatitis in a city with a
population of 30,000 in 2008
• Incidence of hepatitis =
• The Incidence rate MUST contain the time period
500
30,000
X 1000 = 16.7 per 1000
per year

Prevalence
• Prevalence is defined as all cases (old and
new) present at a given point of time or a
period of time in a given population.
• Prevalence is of two types:
– Point prevalence
– Period prevalence

Point Prevalence
• Point prevalence refers to the total number of
cases (old and new) present at given point of
time, usually a day.
• Prevalence of Cutaneous leishmaniasis in
Zawia on 5th May, 2009
• Normally when we say prevalence it is Point
Prevalence

Period Prevalence
• Is the total number of cases (old and new)
existing during a defined period of time in a
defined population.
• Prevalence of Pulmonary Tuberculosis in
Zawia in year 2008

Standardized mortality rate
• Different countries have different population
structure
• So it is possible to compare the mortality rates of
the countries
• We have standardize the mortality rate to make
effective comparisons
• We choose a standard population for comparison

Standardization
• Direct standardization
• Indirect standardization

Direct standardization
• First the age specific death rate of the
population of the country is calculated
• Then a ‗standard‘ population is taken in which
the population of different age groups are
known
• Then the expected death of the standard
population is calculated from the death rate of
the country

Age Mid-year
pop
Deaths Age-sp death rate
0 4,000 60 15.0
1-4 4,500 20 4.4
5-14 4,000 12 3.0
Total 12,500 72
Age specific death rates of a country
Crude death rate = 92/12,500 =
7.36/1000

Standardized death rate
Age Standard
population
Age-sp
death rate
Expected
deaths
0 2,400 15.0 36
1-4 9,600 4.4 42
5-14 19,000 3.0 57
Total 31,000 135
Standardized death rate = 135/31000 x 1000 =
4.35/1000

Physical Quality of Life Index
• Quality of life is difficult to define and
measure.
• One method is to combine three indicators –
Infant Mortality rate, Life expectancy at 1 year
of age and Literacy
• The index is calculated for each country
• The maximum is 100 and minimum 0

Human Development Index
• Human Development Index is calculated from
Longevity (life expectancy at birth),
Knowledge (adult literacy rate and mean
years of schooling) and Income (Gross
Domestic Product per capita)
• Maximum is 1 and minimum 0

Summary
• Health indicators are used for measuring the
health status of a community
• It can also be used to compare health status
of two countries or the same country between
two time periods
• There are many mortality and morbidity
indicators

Chapter 9
Food Hygiene
(‫)النظافة‬ and
Food poisoning

Contents
• Importance of food hygiene
• Food-borne diseases
• Prevention of food-borne diseases

Food hygiene
• Food is a very important route of infection
• Food can be contaminated at any point from
production to consumption(‫)استهالك‬
• Food can be contaminated with microbes like
bacteria and virus or with harmful chemical
substances
• Food hygiene is the science of clean and safe
practices during food production, distribution,

Food-borne diseases
• Bacterial – Typhoid fever, salmonellosis,
dysentery
• Viral – viral hepatitis, poliomyelitis
• Parasitic – tapeworm, roundworm,
amoebiasis
• Chemical poisons – Pesticides
• Others (due to toxins) – lathyrism,
aflatoxicosis

Prevention of food-borne
diseases – Food Handlers
• Persons having diseases like typhoid, viral
hepatitis, diarrhea, infected wound etc.
should not touch, cook or serve food
• People handling food should be educated
about the importance of food hygiene and
how to prevent contamination of food
• They should be kept under medical
surveillance(‫)المراقبة‬

diseases - milk
• Microbes grow very fast in milk, so milk
hygiene is very important
• Milk should be pasteurized before storage
• Domestic milk should be boiled or kept in
refrigerators

diseases – meat hygiene
• Meat of animals suffering from disease can
infect people
• Contamination can occur after slaughter (‫)الذبح‬
of animals
• Tapeworm, Hydatid disease, Anthrax etc.

Meat hygiene
• So only healthy animals examined and
approved by veterinary doctors should be
killed for meat
• Meat should be stored at low temperature to
prevent bacterial growth

diseases – General principles
• Food must be cooked at the right temperature
and duration
• Food must be stored at low temperature for
future use
• Food must be kept covered to prevent flies
from sitting on it
• The floor and surroundings where food is
cooked and stored must be clean and free of

Prevention of food-borne diseases
• Vessels used for cooking must be cleaned
without any leftover food
• Manufacturer‘s instructions must be followed
for processed food
• Do NOT use if you suspect the food is not
safe
• Food items must not be stored with other
poisonous substances and chemicals

Conclusion
• Food hygiene is very important for
maintaining the health of the community.

Food poisoning
Community Medicine

243
Food poisoning
• Food poisoning is an acute disease caused
by ingestion of food or drink contaminated
with either bacteria, their toxins or other
chemicals
• Types of food poisoning
– Bacterial – Salmonella, Staphylococcus, Botulism
– Non-bacterial

244
Salmonella food poisoning
• Agent – S. typhimurium, S. enteritidis
• Source of infection
– contaminated milk, milk products, eggs, egg
product
– Animals like rat, mice
• Incubation period is 12-24 hours
• Common symptoms are – nausea, vomiting,
diarrhea, fever etc

246
Staphylococcal food poisoning
• Agent – S. aureus
• Source of infection – man (boil/pustule) or
animals (contaminated milk or milk products)
• The bacteria produces toxin which causes the
disease
• Incubation period – 1-6 hours

247
Botulism
• Agent – Cl. Botulinum
• Source of infection – sausages, cheese
• Caused by pre-formed toxin
• Symptoms are NOT gastrointestinal
– Dysphagia, diplopia, ptosis, dysarthria, muscle
weakness and sometimes quadriplegia
• If untreated can result in death due to cardiac
or respiratory failure

248
Prevention and control
• Primary prevention
– Food hygiene and personal hygiene
– Proper storage of food
• Low temperature for long storage
• Cover food to protect from flies and dust
– Food handlers
• Should be free of boils/pustule, infected wounds,
diarrhea

249
Secondary prevention
• Early diagnosis and treatment
– Antitoxin for botulism

Chapter:10
Epidemiology of
Communicable Diseases
“Infectious diseases will last as long as
humanity itself”
Measles

Respiratory Infections
Measles (Rubeola)
• An acute highly infectious disease of
childhood caused by a specific virus of the
group myxoviruses. It is clinically
characterized by fever and catarrhal
symptoms of the upper respiratory tract
(coryza, cough)`, followed by a typical rash
• Measles is associated with high morbidity &
mortality in developing countries.

History
• The word ―rubeola‖ means red spots. The
earliest description of measles was given by
the noted Arap physicians, Abu Bact (856 –
925 AD) know to the west as Rhazes.
• Panun did classical studies on the
epidemiology of measles in 1846.
• In 1954, measles virus was isolated by
Enders and his colleagues in USA. In 1958,
measles vaccine was first used in a clinical
trial and 1963, live measles vaccine was

Problem Statement
• Measles is endemic virtually in all parts of the
word. It tends to occur in epidemics when the
proportion of susceptible children reaches
about 40%. When the disease is introduced
into the virgin community more than 90% of
that community will be affected.

• The mortality of measles varies greatly in
different parts of the word. It is 100 to 400
times more likely to cause death in a
preschool child of a developing country, than
it is in the US and Europe. In developing
countries case fatality ranges from 2 – 15%
as compared to less than 0.2 per 10,000
notified cases in developed countries.

• Before the vaccines became available in
1960s, measles killed between 7 and 8
million children a year, and caused an
estimated 135 million cases per year
worldwide. Today it still kills about 1 million
children of the estimated 30 million who gets
measles. Thus measles is leading killer
among vaccine-preventable diseases of
childhood, taking its toll mainly among

• Based on implementation of combination of
measles immunization and surveillance
strategies worldwide, countries are
considered to be in one of the three stages:-
a) Control i.e. reduction of incidence to an
acceptable level as a result of deliberate
efforts, requiring continued control
measures. The objective is to achieve high

b) Outbreak prevention i.e. aggressive immunization strategies
have prevented forecasted outbreak.
c) Elimination i.e. reduction of incidence to ‗zero‘ as a result of
deliberate efforts requiring control measures.
• WHO‘s measles elimination strategies comprises a three
part vaccination strategy, i.e. catch-up, keep-up and follow-
up, two which are supplementary vaccinations. Catch-up is
defined as one time, nationwide vaccination campaign
targeting usually all children aged 9 months to 14 years
regardless of measles disease or vaccination status.

• Keep-up is defined as routine service aimed
at vaccinated more than 95% of each
successive cohort.
• Follow-up is defined as subsequent
nationwide vaccination campaign conducted
every 2 4 years targeting usually all children
born after the catch-up campaign.
• Supplementary vaccination campaign have
been conducted in several countries targeting

• Although measles immunization is an
effective strategy to prevent cases, outbreaks
can continue to occur, specially in densely
populated areas such as urban slums, even
with good coverage. This is because vaccine
efficacy is only 85% and because there are
pockets of poorly immunized children.
• As the coverage increases, the time in
between outbreaks increases, and a shift
towards older age group may be seen as in

• The priorities in countries pursuing measles control
include:-
1. Improve routine vaccination coverage level to at least 90%
2. Active coverage of more than 90% in catch-up and follow-
up campaigns or active coverage of more than 90% with
routine second dose of measles vaccine
3. Establish case-based surveillance with laboratory
confirmation of suspected cases and virus isolation from all
chains of transmission and
4. Conduct supplementary vaccination campaign together
with administration of vitamin A in high risk areas.

• While measles is now rare in many
industrialized countries, it remains a common
illness in many developing counties. More
than 30 million people are affected in each
year by measles. In 2004, it was estimated
that there were 454000 measles death
globally – this translates to more 1200 deaths
every day or 50 deaths every hour from
measles.
• The primary reason for continuing high

• In Somaliland, measles is major cause of
morbidity and significant contributor to
childhood mortality. Although there is no data
at all !.

Epidemiological Determinants
Agent Factor
a) Agent – measles is caused by an RNA paramyovirus. So
far as is known, there is only one serotype. The virus
cannot survive outside the human body for any length of
time but retain infectivity when stored at sub-zero
temperature. The virus has been grown in cell cultures.
b) Source of infection – the only source of infection is
measles case. Carriers are not known to occur. There is
some evidence that subclinical measles occurs more often
than previously though
c) Infective material – secretions of the nose during the
prodromal period and the early stage of skin rash.

d) Communicability – measles is highly infectious during the
prodromal period and at the time of eruption.
Communicability declines rapidly after the appearance of
the rash. The period of communicability is approximately 4
days before and 5 days after the appearance of rash.
Isolation of the patient for a week from the onset of rash
more than covers the period of communicability.
e) Secondary attack rate – there is a only one antigenic type of
measles virus. Infection covers life long immunity. Most so-
called secondary attacks represent errors in diagnosis
either initial or second illness.

Host Factors
a) Age – Affects virtually everyone in infancy or childhood – between 6
months and 3 years in developing countries where environmental are
poor, and children usually over five years in developed countries.
Following the use of measles vaccine, the disease is now seen in
somewhat older-age group. This highlights the periodic serological
checking of the immunity status of the susceptible population.
b) Sex - Incidence is equal
c) Immunity – No age is immune if there is no previous immunity. One attack
of measles generally offers life-long immunity. Second attack is rare.
Infants are protected by maternal up to 6 months of age, in some,
maternal immunity may persist up to 9 months. Immunity after
vaccination is quite solid and long lasting.

d) Nutrition – measles tends to be very severe in malnourished
child, carrying a mortality of 400 times higher than in well-
nourished children having measles. This may possibly
related to poor cell-mediated immunity response, secondary
to malnutrition. Additionally, severely malnourished children
have been shown to excrete measles virus for longer period
than better nourished children indicating prolonged risk for
themselves, and of intensity of spread to others
• Even in a healthy child a severe attack of measles may be
followed by weight loss, precipitating the child into
malnutrition.

Environmental Factors
• Given a chance, virus can spread in any
season. In temperate climates, measles is a
winter disease, probably because people
crowd together in doors. Population density
and movement do effect epidemicity. In
general, the less favourable the prevailing
socio-economic conditions, the lower the
average age at which chlidren are attacked.

Transmission
• Transmission occurs directly from person to
person mainly by droplet infection and droplet
nuclei, from 4 days before onset of rash and
until 5 days thereafter.
• The portal of entry is the respiratory tract.
Infection through conjunctiva is also
considered likely as the virus instilled into the
conjunctiva can cause infection. Recipients of

Incubation Period
• Incubation period is commonly 10 days from
the exposure to the onset of the fever, and 14
days to the appearance of the rash. When
measles infection is artificially induced by-
passing the respiratory tract (as with injection
of live measles vaccine), the incubation
period is somewhat shortened, averaging 7
days.

Clinical Features
• There are three stages in the natural history
of measles, viz. prodromal or pre-eruptive
phase, eruptive stage of post-measles
stage:-

1. Predromal Stage
• It begins 10 days after infection, and
lasts until day 14. it is characterized by
fever, coryza with sneezing and nasal
discharge, cough, redness of the eye,
lacrimation and often photophabia
• There may be vomiting or diarrhoea. A day or two
before the appearance of the rash Koplik‘s spots
appear on the buccal mucosa opposite the first and
second upper molars. They are small, bluish-white
spots on red base, smaller than the head of a pin.
Their appearance is pathognomic of measles.

2. Eruptive Phase
• This phase is characterized by a typical, dusky-red, macular
or maculo-papular rash which begins behind the ears and
extends rapidly down in few hours over the face and the
neck, and extends to down to the body taking 2 – 3 days to
progress to the lower extremities.
• The rash may remain discrete, but often it becomes
confluent and blotchy. In the absence of complications, the
lesions and fever disappear in 3 or 4 days signalling the end
of the disease. The rash fades in the same order of
appearance leaving a brownish discoloration which may
persists for 2 months or more.

• Diagnosis of measles is based on the typical
rash and Koplik‘s spots. The diagnosis is
would normally be incorrect in any febrile
exanthem in which red eyes and cough are
absent. In developed countries where
measles is uncommon, specific antigen IGM
antibodies are being used for diagnosis.

3- Post Measles Stage
• The child will have lost weight and will remain
weak for number of days. There may failure
of to recover and gradual deterioration into
chronic illness- due to increased susceptibility
to other bacterial and viral infections,
nutritional and metabolic effects and the
tissue destructive effects of the virus.
• There may growth retardation and diarrhoea,

Complications
• Measles is too considered as an unimportant infection but
this is not true. The most common complications are:-
1. Measles-associated diarrhoea
2. Pneumonia
3. Otitis media and other respiratory complications
4. Neurological complications ( febrile convulsions,
encephalitis, sub-acute sclerosing encephalitis, sub-acute
scelerosing panencephalitis which is rare and develops
many years after the initial measles infection)

• Measles vaccination is definitely constitutes a
protection against the neurological and other
complications by preventing natural measles
from occurring.
• All cases of severe measles, and all cases in
areas with high case-fatality should be
treated with vitamin A, as many children
develop acute deficiency of vitamin A, which
may lead to keratomalcia and blindness from
corneal scarring.

Prevention of Measles
• The following guidelines are important in
combating measles:-
1. Achieving an immunization rate of over 95%
and
2. On-going immunization against measles
through successive generations of children.

1- Measles Vaccination
• Measles is best prevented by active immunization. Only
live attenuated vaccine are recommended for use; they are
both safe and effective.
1. Vaccine
• No egg culture vaccines are produced at all today, all are
tissue culture vaccine –either chick embryo or human
diploid cell line. The vaccine is presented as a freeze dried
product. It is most important to store the vaccine at
recommended temperature. Heat stable measles vaccine,
able to maintain their potency for more than 2 years at 2 –
8 deg C, have been developed.

2- Age
• The principal problem of measles
immunization is timing; immunization before
9 months runs the risk of the vaccine being
rendered ineffective by the natural
antibodies acquired through the mother.
Immunization later than 9 months means
that a significant proportion of children will
contact measles in the interval between
wearing off natural protection, and the
introduction of the vaccine.

• The WHO Expanded Immunization
Programme (EPI) recommends immunization
at 9 months of age. This age can be lowered
to 6 months if there is measles outbreak in
the community. For infants immunized
between 6 months and 9 months of age, a
second dose should be administered as soon
after the child reaches the 9 month provided
that at least 4 weeks have elapsed since the

• In countries where the incidence of measles
has declined, the age of immunization in
being raised to 15 months in order to avoid
the blocking effect of persistent transplacental
acquired antibody.
• Studies have shown that in most of the
developing countries, nine months is the
optimal age for measles immunization. This

• But experts opine that this should not prevent
health workers from administering measles
vaccine to 6 – 8 months-old malnourished
children who are at high risk of complications
from natural measles and who may not return
at 9 months of age. If these children do not
return, they should receive a second dose of
measles as soon possible after 9 minths.

3- Administration
• The reconstituted vaccine is administered in a
single dose subcutaneous dose of 0.5ml. The
diluting fluid for reconstituting the vaccine
must be kept cold a 4 – 8 deg C. The
reconstituted vaccine should be kept on ice
and used within one hour.
• Measles vaccine is has recently been
adopted in aerosol administration.

4- Reactions
• When injected into the body, the attenuated
virus multiplies and induces a mild ―measles‖
illness (fever and rash) 5 to 10 days after
immunization. This may occur in 15 – 20
percent of vaccinees. The fever may last for 1
– 2 days and the rash for 1 – 3 days.
• There is no cause for alarm. The vaccine now
given rarely causes severe reaction. There is

5- Immunity
• The vaccine has convincingly demonstrated
to provide immunity to even severely
malnourished children. Immunity develops 11
to 22 days after vaccination and appears to
be of long duration, probably for life. One
dose of the vaccine appears to give 95%
protection.

6- Contacts
• Susceptible contacts over the age of 9 – 12
months may be protected against measles
with measles vaccine, provided that this given
within 3 days of exposure. This is because,
the incubation period of measles induced by
the vaccine is about 7 days, compared with
10 days for the naturally acquired measles.

7- Contraindications
• Pregnancy is a positive contraindication.
Others include acute illnesses, deficient cell
mediated immunity, and use of steroids or
other immuno-suppressive drugs.

8- Adverse Effects of Vaccine
• Toxic shock syndrome (TSS) occurs when
measles vaccine is contaminated or the same
vial is used for more than one session on the
same day or the next day.
• The vaccine should be not used after 4 hours
of opening the vial. TSS is totally preventable
and reflects poor quality control of
immunization services.

• The symptoms of TSS are typical. Severe
watery diarrhoea, vomiting and high fever are
reported within few hours of measles
vaccination. There are usually a cluster of
cases as all infants vaccinated from
contaminated vial will be affected.
• This may cause death within 48 hours. Case
fatalities are high.

9- Combined Vaccine
• Measles vaccine can be combined with other
life attenuated vaccines such as mumps and
rubella (MMR vaccine) and such
combinations are also highly effective.

2- Immunoglulins
• Measles may be prevented by administration
of immunoglobulin ( human) early in the
incubation period. The dose recommended
by WHO is 0.25 ml per Kg of body weight. It
should be given within 3 – 4 days of
exposure. The person passively immunized
and should be given live measles vaccine 8 –
12 weeks later. The need of immunoglobulin

Eradication of Measles
• It is believed that measles, like smallpox, is amenable
to eradication. Measles immunization has in its favour
the fact that only one dose is needed, and that a
measles vaccine has now been developed which is
more heat soluble.
• it requires:-
a) A achieving an immunization coverage of at least 96%
of children under one year of age and
b) The cumulation in the immunity gap be prevented.

Control of Measles
• The following control measures have
been recommended:-
a) Isolation for 7 days after onset of rash
b) Immunization of contacts within 2 days of
exposure (if vaccine is contraindicated,
immunoglobulin should be given with 3 –
4 days of exposure) and
c) Prompt immunization of the beginning of
an epidemic is essential to limit the

•Thank you for
your attention

Whooping Cough
• An acute infectious disease, usually of young
children, caused by B. pertussis. It is
characterized by insidious onset with fever
and irritating cough, gradually becoming
paroxysmal with the characteristic ―whoop‖
(loud crowing inspiration). The spectrum of
disease varies from severe illness to atypical
and mild illness without whoop. The Chinese
call it a ―hundred day cough‖.

Problem Statement
• Whooping cough occurs in all the countries.
Since the beginning of this century, there has
been a marked and continuous drop in
deaths from whooping cough. Nevertheless in
many parts of the world, pertussis is still a
clinically serious illness, with high mortality
and complication rates.

• Whooping cough occurs endemically and
epidemically. In tropical countries, it rivals
measles in importance and severity among
children. Since the reporting of whooping
cough is usually inadequate, reliable
information about incidence of the disease is
lacking in most counties.
• However, since it become vaccine

• Whooping cough occurs worldwide but most deaths are in
countries of Africa, Asia, and Central and Latin America.
• Cases are on the increase in some Eastern European
countries. It is one of the most lethal diseases of infants and
young children who have not been vaccinated, particularly
those with underlying malnutrition and other respiratory
infections such as pneumonia. Cases fatality in developing
countries range from 4 – 15% in infants. About 10% of all
whooping cough cases and about half of the deaths occur in
children under year of age.

• Recent studies have shown that the immunity
wanes significantly after few years after
immunization, but it would be susceptible to
booster doses (responds well to the booster
dose).
• According to WHO, the global burden of
disease in terms of daily lost is in 2002 was
about 12.95 million.

Agent Factors
a) Agent
• The causative agent is a large proportion of
cases in B. pertussus. In small percentage
cases (less than 5 percent), B.
parapertussis is probably responsible.
• Certain viruses (e.g. adenovirus,
parainfluenza viruses) are also implicated in
the whooping cough syndrome, but their
presence in cases of whooping cough is

• B. pertussis occurs in smooth and rough
phases, capsulated and non-capsulated
forms, and elaborates an exotoxin and
endotoxin. Clinical disease is associated with
encapsulated, phase 1 strains.
• B pertussis is antigenically highly complex. It
caries 3 major agglutinogens (any Ag that
provokes the production of Ab - 1, 2 & 3, and

• The bacterium survives only for very short
periods outside the human body.
b) Source of infection
• Bacteria infects only man. The source of
infection is a case of pertussis, more often
the source may be mild, missed and
unrecognized case. There is no evidence that
infection is ever subclinical.

c) Infective Material
• The bacilli occur abundantly in the nasopharyngeal and
bronchial secretions, which are infective. Objects freshly
contaminated by such secretions are also infective.
d) Infective period
• Whooping cough is most infectious during catarrhal stage.
The infective period may be considered to extend from a
week after exposure to about 3 weeks after the onset of
paroxysmal stage. The disease is unlikely to be infectious
before the child has developed catarrhal symptoms.
e) Secondary attack rate:
• Averages 90% in unimmunized household contacts.

Host Factors
a) Age
• Whooping cough is primarily a disease of
infants and preschool children. The highest
incidence is found below 5 years. The
median age of incidence, i.e. the age when
half the children are likely to develop
whooping cough is between 20 – 30 months
in developing countries as compared to 50
months in developed countries.
• Infants below 6 months have highest

b) Sex
• Incidence and fatality are observed to be
more among female than males.
c) Immunity
• Recovery from whooping cough or adequate
immunization is followed by immunity.
Second attacks may occur in person with
declining immunity, but these are usually
mild. Infants are susceptible to infection from
birth because maternal antibody does not

• Pertussis occurs throughout the year, but the
disease shows a seasonal tend with more
cases occurring during winter and spring
months, due to overcrowding, socioeconomic
conditions and ways of life also play a role in
the epidemiology of the disease. Thus the
risk of exposure is greater in the lower social
classes living in overcrowded conditions than
in well-to-do groups.

Mode of Transmission
• Whooping cough is spread mainly by droplet
infection and direct contact. Each time the
patient coughs, sneezes or talks, the bacilli
are sprayed in the air. Most children contract
infection from their playmates who are in
early stages of the disease. The role of
fomites in the spread of infection appears to
be very small, unless they are freshly

Incubation Period
• Usually 7 to 14 days, but not more than 3
weeks.
Clinical Features
• B. pertussis produces a local infection; the
organism is not invasive. It multiplies on the
surface epithelium of the respiratory tract
and causes inflammation and necrosis of the
mucosa leading to secondary bacterial
invasion. Three stages are described in the

a) Catarrhal stage, lasting for about 10 days
b) Paroxysmal stage, lasting for 2 – 4 weeks
and
c) Convalescent stage, lasting for 1 – 2 week.
The illness generally lasts 6 to 8 weeks.
• The chief complications af pertussis are
bronchitis, bronchopneumonia and
brochiectasis. The violence of the
paroxysms may precipitate subconjunctival
haemorrhages, epistaxis, haemoptysis and

Control of Whooping Cough
1. Cases and Contacts
i) Cases:-
• Early diagnosis, isolation and treatment of
cases, and disinfection of discharged from
nose and throat are the general principles
of control of whooping cough.
• Early diagnosis is possible only by
bacteriological examination of nose and
throat secretions which may be obtained by

• The chances of isolation is 80 – 90% if the material is
obtained 10 – 14 days from the onset of illness. The
value of fluorescent antibody technique has been
emphasized in facilitating the rapid diagnosis of
pertussis.
• Although several antiboitics is effective. Erythromycin is
probably the drug of choice. A dose is 30 – 50mg/kg of
body weight in 4 divided doses for 10 days has been
recommended. Alternatives include ampicillin, co-
trimoxazole or TTC. Antibiotics do not reduce the
frequency or severity of spasm not they shorten illness.
They usually useful in controlling secondary bacterial
infections.

ii) Contacts
• Infants and young children should be kept
away from cases. Those known to have been
in contact with whooping cough may be given
prophylactic antibiotics (erythromycin or
ampicillin) treatment for 10 days to prevent
the infecting bacteria to become established.
• The best protection that can be given to an
infant is to be administer a booster dose of

Active Immunization
i) DPT
• National policy is to immunize against diphtheria,
whooping cough and tetanus simultaneously, by
administering 3 doses (each dose 0.5ml) of DPT vaccine
IM, at 1 – 2 months interval, starting when the infant is
about 6 weeks old. If the pertussis is prevalent in the
community, immunization can be started earlier at the age
of 1month.
• At this age, the immune response is poorer, but some feel
that the partial protection obtained is better than no
protection. A booster dose of DPT is indicated at the age
of 18 – 24 months.

ii) Pertussis Vaccine
• An effective vaccine is also available against
pertussis alone. It is killed whole cell
preparation. To be effective, the vaccine must
contain the surface components
(agglutinogens 1, 2, and 3), and the lack of
anyone renders the vaccine inadequate.

• UNTOWARD (difficult to manage)
REACTIONS: with some vaccines available
in early 1960s, persistent screaming (loud
sharp penetrating cry or noise) and collapse
were reported, but these reactions are rarely
observed with the vaccines now available.
Pertussis vaccines may give rise to local
reactions at the site of injection, mild fever
and irritability.
• Experience have shown, however, when

Contraindications
1. Personal and strong family history of
epilepsy, convulsions or similar CNS
disorders
2. Any febrile upset until fully recovered
3. Reactions to one of the previously given
triple vaccine injections

Passive Immunization
• The merit of hyperimmune globulin in
pertussis prophylaxis has yet to be
established. So far there is no evidence of
its efficacy in well controlled trials.
• Control of pertussis by immunization is still
unsolved problem. Even if the level of
immunization reaches 100%, it is possible
that the disease would not entirely
eliminated because whooping cough

•Thank you for your
attention

Diphtheria
• Diphtheria is an infectious disease caused by
toxigenic strains of Corynebacterium
diphtriae, three clinical types have been
described: anterior nasal, faucial and
laryngeal; however, the skin, conjunctiva,
vulva and other parts of the body may be
affected. The bacilli multiply locally, usually in
the throat, and elaborate a powerful exotoxin
which is responsible for:-

1. The formation of a greyish of yellowish membrane
(false membrane) commonly over the tonsils,
pharynx or larynx (or at the site of implantation) with
well defined edges and the membrane can not be
wiped away;
2. Marked congestion, oedema or local tissue
destruction;
3. Enlargement of the regional lymph nodes; and
4. Signs and symptoms of toxaemia

• Fatality rate on the average is about 10%
which has changed little in the past 50 years
in untreated cases, and about 5% in treated
cases.

Problem Statement
• WORD: Diphtheria is a rare disease in most
developed countries owing to routine children
vaccination. In countries where satisfactory
vaccination schemes have been instituted the
disease has so declined that it is no longer
regarded as a public health problem.
However, the disease is seen occasionally
among non-immunized children in developed
countries.

• Improved socio-economic conditions are
changing epidemiology of diphtheria.
Changes in life style allow far less opportunity
to maintain natural immunity, such as through
frequent skin infection with C. diphtheriae. An
example of waning immunity is the outbreak
of diphtheria reported in Russia Federal,
Ukraine in 1990 and Thailand and Laos in

• Approximately 300 cases were reported by
Laos and majority of cases were
between 3 – 15 years.
• These epidemics are largely due to
decreasing immunization coverage among
infants and children, waning immunity to
diphtheria in adults, movement of large of
population in the last few years, and irregular
supply of vaccine.

• These outbreaks highlight the need for booster vaccinations.
Recent diphtheria outbreaks in a number of countries have
demonstrated a shift in the age distribution of cases to older
children and adults.
• In developing countries, the disease continues to be
endemic due to lack of adequate widespread immunization.
The true number of diphtheria cases and deaths are
unknown because of incomplete reporting from most
countries where the disease occur, WHO estimates for the
global burden of disease in terms of healthy life lost
attributable to diphtheria in about 185,000 DALYs for the
year of 2002. about 5000 died due to diphtheria in the same

Agent Factors
a) AGENT:
• The causative agent, C. diphtheriae is a
gram-positive, non-motile organism. It has
no invasive power, but produces a powerful
exotoxin. Three typed of diphtheria are
differentiated – gravis, mitis and intermedia
all pathogenic to man.

• In general, gravis infection tend to be more
severe than mitis infections. Not all strains of
the organism are toxigenic. There is evidence
that a non-toxigenic strain may become
toxigenic exposed to particular bacteriophage
– the beta phage – carrying the gene for the
toxin production. The toxin can effect the
heart leading to myocarditis or the nervous
leading to paralysis.

• Diphtheria bacilli are sensitive to penicillin
and readily are killed by heat and chemical
agents. They may survive in short periods in
dust and fomites.
b) SOURCE OF INFECTION:
• Source of infection may be a case or carrier.
Case range from subclinical to frank clinical
cases. Mild or silent cases may exhibit no
more than a mere running nose or sore
throat; these cases play a more important

• Carrier are common source of infection, their
ratio is estimated to be 95 carriers for 5
clinical cases. Carriers may be temporary or
chronic, nasal or throat carriers. The nasal
carriers are particularly dangerous as source
of infection because of frequent shedding of
organism in to the environment, than the
throat carriers. The temporary carriers state

• The incidence of carriers in a community may
vary from 0.1 to 5 %. The immunization does
not prevent the carrier state.
c) PERIOD OF INFECTIVIY
• Unless treated, the period of infectivity mat
vary from 14 to 28 days from the onset of the
disease, but carriers are remain infective for
much longer periods. A case or carrier may
be considered non-communicable , when at
least 2 cultures properly obtained from the

Host Factors
a) Age:- Diphtheria particularly affects children aged 1 to 5. in
countries where widespread immunization is practised, a
shift in age incidence has been observed from preschool to
school age
b) Sex:- both sexes are affected
c) Immunity:- infants born of immune mothers are relatively
immune during the first few weeks or months of life. A
large proportion of population in developing countries
seem to be require active immunity through in apparent
infection.

• Schick test surveys the level of immunity in
the community. A herd immunity over 70% is
considered to prevent epidemic spread, but
some believe that the critical level may be as
high as 90%.

• Cases of diphtheria occur all seasons,
although winter months favour its spread.
• Mode of Transmission
- the disease mainly spread may droplets.
It may also transmitted directly to susceptible
persons from infected contagious lesions.
- transmission by objects (i.e. cups,
thermometers, toys, pencils) contaminated by
nasopharyngeal secretions of the patient is

• Portal of entry:-
a) Respiratory root
- commonly the portal of entry is the respiratory tract
b) Non-respiratory tract
- the portal of entry may be some times skin where
cuts wounds and ulcers not properly attended to, may
get infected with diphtheria bacilli, and so is the
umbilicus in the newborn.
Occasionally, the site of implantation may be the eye,
genitalia or middle ear. The non-respiratory routes of
infection are less common in developed countries where
spread by droplet infection is more common.

• Incubation period
- 2 to 6 days, occasionally longer.
Clinical Features
• Respiratory forms of diphtheria consists pharyngotonsillar,
laryngotracheal, nasal and combination of these. Pateints
with pharyngothrachea diphtheria have a sore throat,
difficulty in swallowing, and low grade fever at presentation.
• Examination of throat may show only mid erythema,
localized exudate or membrane. The membrane may be
localised or a patch of the posterior pharynx or tonsils. May
cover the entire tonsil, or less frequently, may spread to
cover the soft and had palate and the posterior portion of
the pharynx.

• In the early stage, the membrane may be
whitish and may wipe of easily. The
membrane may extend to become thick, blue-
white to grey-black, and adherent. Attempts
to remove result in bleeding.
• Patients with severe disease may have
marked oedema of the submandibular area
and the anterior portion of the neck. Along

• Laryngotracheal diphtheria mos often is
preceded pharygotonsillar disease, usually is
associated hoarseness and croupy cough at
presentation, and if the infection extends into
bronchial three, is the most severe form of
disease.
• Initially it may not be distinguishable from
viral croup or epiglottis.
• Nasal diphtheria, the mildest form respiratory
diphtheria, usually is localised at the septum

• Cutaneous diphtheria is common in tropical
areas. It often appears as a secondary
infection of previous skin abrasion or
infection. The presenting lesion, often an
ulcer, may be surrounded by erythema and
covered with membrane . Patients seek for
care because of the chronicity of the skin
lesion.

Control of Diphtheria
1- Cases and carriers
a) Early detection
• An active search for cases & carriers should start
immediately among family and school contacts. Carriers
can be detected only by culture methods. Swabs should be
taken both from nose and throat and examined by cultural
methods for diphtheria bacilli. Tests should be made for
the virulence of the organism.
• b) isolation:- All cases, suspected cases and caries should
be promptly isolated, preferably in a hospital, for at least
14 days or until free o infection. At least 2 consecutive
nose or throat swabs, taken 24 hour apart, should be
negative before termination of isolation.

• c) Treatment
i) Cases:-
• When diphtheria is suspected, diphtheria antitoxin, 10, 000 to 80, 000
units or more, depending upon the severity of the case, after a
preliminary test dose of 0.2 ml subcutaneously to detect sensitization
to horse serum. In addition to antitoxin, every case should be treated
with penicillin (2.5 million IU units every 6 hours) or Erythromycin (250
mg every 6 hours for 5 to 6 days to clear the throat if C.diphtheriae
and there by decrease of reduction of the toxin.
ii) Carriers
• The carriers should be treated with 10 day course of oral
erythromycin, which is the most effective drug for the treatment of
carriers. Immunity status should be upgraded as discussed below.

2- Contacts
• Contacts merit special attention. They should be throat
swabbed and their immunity status determined. Different
situations pose different options:-
a) Where primary immunization or booster dose was received
within the previous 2 years, no further action was would be
needed
b) Where primary course of or booster dose of diphtheria was
received more than 2 years before, only a booster dose of
diphtheria toxoid need be given.
c) Non-immunized close contacts should receive a
prophylactic antibiotics penicillin or erythromycin. They
should be given 1000 – 2000 units o diphtheria antitoxin

• Contacts should be placed under medical
surveillance and examined daily for evidence
of diphtheria for at least a week after a
exposure. The bacteriological surveillance of
close contacts be continued for several
weeks by repeated swabbing by
approximately weekly intervals.

Community
• The only effective control is by active
immunization with diphtheria toxoid of all
infants as early as scheduled with
subsequent booster every 10 years
thereafter.
• The aim should be to immunize before the
infant loses his maternally derived immunity
so that there will be continuous protection

• The vaccine being is toxoid is not directed
against organism. There vaccine does not
prevent carrier state, consequently, the non-
immune individuals are not protected by high
level of population immunity. This implies that
immunization rate must be maintained at a
high level.

Diphtheria Immunization
Current Prophylactics
a) Combined or mixed vaccines:-
- DPT(diphtheria-pertussis-tetanus)
- DT (diphtheria- tetanus)
b) Antisera
- Diphtheria anti-toxoid

Meningococcal Meningitis
• Meningococcal meningitis or cerebro-spinal
fever is an acute communicable disease
caused by N. meningitis. It usually begins
with intense headache, vomiting and stiff
neck.
• The zone between 5 and 15 degree N of the
equator in tropical Africa is called the
―meningitic belt‖ because of the frequent

• During recent years, several serious
outbreaks affecting numerous countries
occurred, not so - called meningitic belt in
Africa but also in both tropical countries and
temperate countries zones of other countries,
vis America, Asia & Europe.
• Meningococcal disease in endemic in
Somaliland, cases of meningococcal

Epidemiological Features
a) AGENT:-
• the causative agent, N. Meningitis is gram
– negative diplococci. Several serotypes
have been identified (A, B, C, X, Y, 29E,
XW135, etc), groups A & C, and a lesser
extend Group B meningococcal are capable
of causing major epidemics.
• Incidence of infections of by Groups Y &

• N. meningitis is a delicate organism, it die
rapidly on exposure to heat and cold.
b) SOURCE OF INFECTION:-
• The organism is found in the nasopharynx of
cases and carriers. Clinical cases present
only a negligible source of infection. More
often infection causes only mild or even
unnoticeable symptoms of nasopharyngitis. 5
to 10% of the normal population may harbour
organism in the nasopharynx during the inter-

• The mean duration of temporary carriers is about 10
months.
• During epidemics the carrier state may go up to 70 – 80%.
c) PERIOD OF COMUNICABILITY
• Until meningococcal are no longer present in the
discharges from nose and throat. Cases rapidly lose their
infectiousness within 24 hours with effective treatment.
d) AGE & SEX:-
• This is a predominantly disease of children and young
adults of both sexes.

e) IMMUNITY:-
• All ages are susceptible. Younger groups are
more susceptible than older groups as their
antibodies are lower. Immunity is acquired by
subclinical infections (mostly), clinical disease
or immunization. Infants derive passive
immunity from their mother.

• The seasonal variation of the disease is well
established, outbreaks occur more frequently
in the dry and cold months of the year.
• Overcrowding as occurs in schools, barracks,
refugee and other camps, is an important
predisposing factors. The incidence is also
greater in the low socio-economic groups
living under poor housing conditions.

Mode of Transmission
• The disease spreads mainly by droplets. The
portal of entry is nasopharynx.
Incubation Period
• Usually 3 to 4 days, but may vary from 2 to
10 days

Prevention and Control
a) Cases
• Treatment with antibiotics can save the lives of 95% of
patients that is started during the first 2 days of illness.
Penicillin is the drug of choice. In-penicillin resistant
patients, CAF, Ceftriaxone can be substituted.
• Treatment of cases has particularly no effect on the
epidemiological pattern of the disease because it only
reduces the fatality rate of the disease according to the
treatment efficacy. Isolation of cases is of limited
usefulness in controlling epidemics because the carriers
outnumber the cases.

b) CARRIERS:-
• Treatment with penicillin does not eradicate
the carrier state; more power full antibiotics
such as rifampicin are needed to eradicate
the carrier state.
c) CONTACTS:-
• Close contacts of persons with confirmed
meningococcal disease are at increased risk
of developing meningococcal illness (about
1000 times the general population). Nearly

• Chemoprophylaxis has been suggested for
close contacts. Current recommendations
regarding chemoprophylaxis of close contacts
are early institution of rifampicin (the drug of
choice unless the organism is known to be
sensitive to sulfadiazine) 600mg twice-a-day
for 2 days for adults. Dosage of sulfadiazine
for adults is 1g twice-a-day for 2 days.

d) Mass Chemoprophylaxis:-
• This is in fact mass medication of the total population some
of which are not infected. It is recommended that mass
chemoprophylaxis be restricted to closed and medically
supervised communities.
• Mass treatment causes an immediate drop in the incidence
rate of meningitis and in the proportion of carriers.
• The efficacy of this preventive measure depends to the large
extent on the population coverage. The other drugs are
ciprofloxacin, minocycline, spiramycin & ceftriaxone.

d) IMMUNIZATION:-
• Effective vaccine prepared from purified Group A, Group
C, Group Y and/or Group 135 meningococcal
polysaccharides are now available. They may be
monovalent (A or C) or polyvalent (A-C, A-C-Y, etc.). It
takes 10-14 days for immunity to develop. Recent field
trials have indicated that immunity will lasts for 3 years,
and booster every 3 years would be reasonable.
• High risk population should be identified and vaccinated.
The vaccine is not recommended for use in infants and
children under 2 years. The vaccine is contraindicated for
the pregnant women.

• Vaccinations in outbreak control:- Since even
large scale coverage with current vaccine
does not provide herd immunity, the current
WHO recommendations for outbreak is to
mass vaccinate to every district that is in
outbreak phase, as well as those contiguous
districts that are in alert phase. It is estimated
that a mass immunization campaign, if
promptly implemented, can avoid 70% of

e) ENVIORONMENTAL MEASARUES:-
• Improved housing and prevention of
overcrowding are long-term measures.
Thank You for your
attention

Viral Hepatitis
• Viral infections may be defined as infection of the liver
caused by any of half dozen of viruses. Twenty years ago,
hepatitis A virus (HAV) and hepatitis B (HBV) were the only
known aetiological agents of viral hepatitis. Today, in
addition to HAV & HBV hepatitis viruses C, D, E & G have
also been identified and are recognized as aetiological
agents of viral hepatitis.
• It is know that many other viruses may be implicated in
hepatitis such as cytomegalovirus, Epstein-Barr virus, yellow
fever virus and rubella virus. Viruses of herpes simplex and
adenovirus can also cause severe hepatitis in immuno-
compromised individuals, but are rare.

Hepatitis A
• Hepatitis A (formerly known as ―infectious‖
hepatitis or epidemic jaundice) is an acute
infectious disease caused by hepatitis A virus
(HAV). The disease is heralded by non-
specific symptoms such as fever, chills,
headache, fatigue, generalized weakness
and aches and pain. Followed by anorexia,
nausea, vomiting, dark urine and jaundice.
• The disease is benign with complete recovery
in several weeks. The case fatality is less

Problem Statement
• Being an enterovirus infection like
poliomyelitis, hepatitis A is endemic in most
developing countries, with frequent outbreaks
of minor or major outbreaks. The exact
incidence of the disease is difficult to estimate
because of high proportion of asymptomatic
cases.
• However according to WHO about 10 – 50

• HAV infection is very common in all the
countries of SEARO, AFRO & EMRO. Poor
standard of hygiene and sanitation facilitate
the spread of HAV in high endemic disease.
The level of circulation in the population is
extremely high.
• sero- epidemiological studies carried out in
India, Bangladesh & Nepal demonstrated that

• For practical purposes the word can be
divided in to areas of low, intermediate & high
endemicity, although there may be regional
differences in endemicity within a country. In
areas of low endemicity the disease occurs
mainly in adolescents and adults.
• In areas of intermediate endemicity, many
individuals escape childhood infection, bur
are more exposed later in life when clinical

• In areas of high endemicty, where the lifetime
risk of infection is greater than 90%, most
infections occur in early childhood and are
asymptomatic. Thus a clinically apparent
hepatitis A is rarely seen in these areas.
• Epidemics of HAV often evolve slowly,
involve wide geographic areas and last many
months, but common source epidemics (e.g.

Agent Factors:-
a) AGENT
• The causative agent is HAV, is an
enterovirus (type 72) of picornoviridae
family. It is only multiplies in the
hepatocytes. Faecal shedding of the virus is
its highest during the latest part of the
incubation period and early acute phase.
Only one serotype is known.

b) RESISTENCE:-
• The virus is fairly resistant to heat and chemicals. It has
been shown to survive more than 10 weeks in well water. It
withstand with 60 degree of Celsius for about one hour and
is not affected by chlorine in doses usually employed for
chlorination.
• Formalin is stated to be an effective disinfectant. The virus is
inactivated by ultraviolet and by boiling for 5 minutes or
autoclaving. In short the virus survives for long periods under
variable conditions and resists many procedures that
eliminate or inactivate most bacterial agents.

b) RESERVOIR OF INFECTION
• The human cases are the only reservoir of
infection. The cases range from
asymptomatic infections to severe ones.
Asymptomatic (anicteric) infections are
especially common in children. These cases
play an important role in maintaining the
chain of transmission in the community.

c) PERIOD OF INFECTIVITY
• The risk of transmitting HAV is greatest from
2 weeks before to 1 week after the onset of
jaundice. Infectivity falls rapidly with the onset
of jaundice and up to one week there after.

Infective Material
• Mainly man‘s faeces. Blood, serum and other
body fluids are infective during the brief stage
of viraemia.
Virus excretion
• HAV is excreted in the faeces for about two
weeks before the onset of the jaundice and
for up to one week thereafter. The virus may
be excreted in the urine.

Host Factors
a) Age
• Infection of HAV is more frequent among children than adults.
However people from all ages may be affected if susceptible. In young
children, infections tend to be mild or subclinical, the severity
increases with age by the age of 10 years, 90% of healthy persons
have serological evidence of HAV infection.
b) Sex
• Both sexes are equally susceptible
c) Immunity
• Immunity after attack probably lasts for life; second attacks have been
reported in about 5% of patients. Most people in endemic areas
acquire immunity through subclinical infections.
• The IGM antibody appears easily in the illness and persists for more
than 90 days. IgG appears more slowly; and persists for many years.

• Cases may occur in throughout the year. In
Somaliland the disease tend to be associated
with periods of heavy rainfall.
• Poor sanitation and overcrowding favour the
spread of the disease, giving rise to water
borne and food borne epidemics.

Mode of transmission
a) Faecal – oral route :- This is the major route
of transmission. It may occur by direct
(person-to-personal contact or indirectly by
way of contaminated water, food or milk.
Water – borne transmission, is not a major
factor in developed countries, where food –
borne outbreaks are becoming more
frequent. For example, consumption of a raw
or inadequately cooked food shellfish

• Direct transmission comprises an array of
routes such as contaminated hands or
objects such as eating utensils.
b) Parenteral route – HAV is rarely, if ever
transmitted by the parenteral route, e.g. by
blood and blood products or by skin
penetrations through contaminated
needles. This may occur during viraemia.

c) Sexual trabsnussion – as STI, HAV may
occur mainly among homosexual men
because of oral-anal contact.
Incubation period
• 15 – 45 days (usually 25 to 30 days), the
length of the time is proportional to the dose
ingested.

Diagnosis
• A specific laboratory diagnosis of hepatitis A
can be obtained:-
a) Demonstration of HAV particles or specific
antigens in the faeces
b) Demonstration of a rise in anti-HAV titre and
c) Detection of IGM antibody to HAV in the
patients serum, this antibody appears early
in the illness, and persists for a limited time,
usually 3 – 4 months after onset, IgG

HIV 381
THANKS A LOT MY
DEAR STUDENTS

chapter: 11
‫ﻢ‬ ‫ﺒﺳﻢﺍﷲﺍﻠﺭﺤﻤﻦﺍﻠﺮﺣﻳ‬
Good morning Ladies & Gentlemen
‫ﻮﺒﺮﻛﺎﺘﻪ‬ ‫ﻮﺮﺤﻤﺔ‬ ‫ﻋﻠﻳﻛﻢ‬ ‫ﺍﷲ‬ ‫ﺍﻠﺳﻠﺍﻢ‬
HIV 382

HIV 384
Global distribution of the Epidemic:
UNAIDS/WHO Report of 2007

HIV 385
Dadka uu ku dhacay sanadkii
2007

HIV 386
Dadka u dhintay sanadkii 2007

HIV 387
HIV prevalence rates in some African countries are already at
alarming levels. Seven countries in sub-Saharan Africa have adult
prevalence rates of more than 17%, with rates exceeding 35% in
Botswana (37.3%) and Swaziland (38.8%). In West Africa,
prevalence rates tend to vary between one and five per cent, while in
East and Central Africa the rates vary from four per cent to 15%.

HIV 388
General points
AIDS is now second only to the Black Death as the largest epidemic in history.
AIDS kills about 2.9 million people a year, or about one person every 11
seconds, as you can see here. This death toll surprisingly includes a lot of
children, who are often infected with the HIV virus during pregnancy or
through breast-feeding

HIV 389
in Africa
• The toll is worst in Africa, where millions
of parents have died, leaving children as
orphans. Often teachers have died as well,
leaving schools empty. Doctors and
nurses have died, leaving hospitals and
medical clinics with nothing. Farmers
have died, leaving crops in the fields.
Entire villages have been devastated.

HIV 390
20 – 39%
10 – 20%
5 – 10%
1 – 5%
0 – 1%
trend data unavailable
outside region
1986 1991
1996 2001
The spread of HIV/AIDS in the African
continent

HIV 393
What could be done
• The toll is worst in Africa, where millions
of parents have died, leaving children as
orphans. Often teachers have died as well,
leaving schools empty. Doctors and
nurses have died, leaving hospitals and
medical clinics with nothing. Farmers
have died, leaving crops in the fields.
Entire villages have been devastated.

HIV 394
How is the situation
• Effectively tackling HIV/AIDS is the world’s most urgent
public health challenge. Already, the disease has killed
more than 20 million people. Today, an estimated 34–46
million others are living with HIV/AIDS. In 2006, 3 million
people died and 5 million others became infected.
Unknown a quarter of a century ago, HIV/AIDS is now
the leading cause of death and lost years of productive
life for adults aged 15–59 years worldwide.

HIV 395
Ways forward
A comprehensive HIV/AIDS strategy links
prevention, treatment, care and support
for people living with the virus. The
interaction of HIV/AIDS with other
infectious diseases is an increasing public
health concern

HIV 396
Situation in S/L:Last surveillance
Report in SL in 2004
• Total +ves %
• Hargeisa 499 8 1.6%
• Berbera 350 8 2.3%
• Borama 362 4 1.1%
• Burao 350 2 0.6%

HIV 397
Prevalence among pregnant women in
Somaliland
HIV Prevalence among Pregnant Women by Sites in Somaliland
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
Hargeisa Berbera Borama Burao
Sites
%Prevalence

HIV 398
SOLNAC operations Framework
SOLNAC Secretariat
National AIDS Commission
(SOLNAC)
Office of the
President
FBOs Private
Sector
NGOs/
CBOs
Community
Regional AIDS Taskforce
Civil Society/
Private Sector
Cabinet Members in
SOLNAC
AIDS Units in the Line
Ministries

HIV 399
0
0.8
1.3
2.2
2.7
0
0.5
1
1.5
2
2.5
3
Prevalence
(%)
Borama Hargeisa Burao Daami IDP Berbera
Sentinel site
HIV prevalence by sentinel site, Somaliland, 2007
HIV Prevalence sentinel, 2007
Median Prevalence= 1.3%
95% CI: 0.8 – 2.2

HIV 400
0.6
2
0.7
1.3
1.3
0
0.5
1
1.5
2
Prevalence(%)
15-19 20-24 25-29 30-34 35-49
Age group (yrs)
Age-specific prevalence of HIV among pregnant
women attending ANCs in Somaliland, 2007 sentinel
survey

HIV 401
Vulnerability factors for the spread of HIV/AIDS
• Low awareness/lack of information/ denial
• High risk behaviour
• Prevalence of other STIs
• Migration and population mobility
• Conflict & displacement
• Poverty and unemployment
• Inadequate health resources and poor access to care
• Cultural and societal factors (remarriage/ ‘dumaal’,
polygamy, FGM, gender inequality)

HIV 402
IPTCS Facilities
ART centres 3
VCTs 8
AIDS/TB 3
PMTCT 2

HIV 403
Prevalence in age group
HIV Prevalence among Pregnant Women in Somaliland
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
15-19yrs 20-24yrs 25-29yrs 30-34yrs >35yrs
Age Groups
%PrevalenceRates

HIV 404
HIV Sero-prevalence in Somaliland
and neighboring countries
• Somaliland = 1.4% generally, 4.3% for those
with STIs and 4.5% in TB cases
• Somalia = 1.1%
• Djibouti = 3%
• Ethiopia =6.7%
• Kenya = 7%

HIV 405
Neighboring
Countries
The 2004 report on
the global AIDS
epidemic on HIV
prevalence among
15-49 year olds in
neighbouring
countries shows:
Djibouti—2.9%
Ethiopia—6.7%
Kenya—4.4%
1.4%

HIV 406
Global status of children
HIV infections in children under
15 (2005)
200480,000570,000HIV/AIDS
deaths
700630,000700,000New HIV
infections
14,0002 million2.3
million
Children
living with
HIV/AIDS
Industrialised
countries
Sub-
Saharan
AFRICA
GLOBAL

HIV 407
Current situation in Africa
• Africa is the region worst affected by HIV/AIDS, with 70 percent of
the world’s 42 million infected people.
• The pandemic has killed 25 million Africans so far and orphaned
more than 12 million others. Each year, 3.2 million Africans – 8,700
Africans every minute — are infected with the HIV virus.
Approximately 2.3 million Africans –most of them in the prime of
their lives as parents and workers-- are killed by it each year.

HIV 408
African situation cont.
• In just over a decade, the HIV/AIDS pandemic has
reversed many of Africa’s development
achievements of previous decades. It has reduced
life expectancy in some countries by nearly 40 years
and is the leading cause of death on the continent.
The pandemic has emerged clearly as the
paramount threat to development in the region.
•

HIV 409
African situation cont.
• Of the 25 million Africans living with HIV, close
to 4 million have advanced to the stage where
antiretroviral drugs are necessary to forestall or
reverse the onset of full-blown AIDS. Yet, only
100,000 of all those infected in Africa have
access to treatment

HIV 410
What is the difference between HIV
& AIDS
• HIV is the causative agent which is a virus
and the three words stands for:
H= Human
I = Immune deficiency
V = Virus
AIDS is the disease caused by HIV.
A = Acquired, I= Immune, D=Deficiency
S= Syndrome

HIV 411
History of HIV
• HIV/AIDS case have identified in US in early 1980s.
• The virus HIV 1 is Isolated in 1984 in France while HIV II
was isolated in 1986.

HIV 413
HUMAN IMMUNODEFICIENCY
VIRUS
• HIV 1 was isolated in 1984, HIV 2 in ‗86.
• It was then found to belong to the family of
viruses called RETROVIRUSES.

HIV 414
HIV Replication Cycle
HIV particle
Injection
of
contents
HOST CELL
Binding
Binding
sites
RNA DNA
Reverse
transcription Transcription
Integration of provirus
DNA into host DNA
Translation
Cell
membrane
Completed
HIV particle
Maturation
Budding
Viral
assembly
Protein
cleavage
gp41 gp120
RNA s
e
Protease
Integrase
Provirus
(circular
structure)
HIV Particle
CD4 Cell
1. Binding
2. Injection of
Capsid Contents
3. Reverse
Transcription
4. Translation
5. Viral Assembly
6. Budding

HIV 415
Mode of Action of ARV‟s
 All ARV‘s work by preventing multiplication of the HIV
particle
 They work at different stages of the replication cycle
 If HIV cannot multiply, it is prevented from destroying the
CD4 Cells
– Detailed knowledge of the mechanism of action of ARV‘s is of
academic interest, but it is not of great practical importance for
prescribers

HIV 416
Targets of ARV drugs
HIV particle
Injection
of
contents
HOST CELL
Binding
Binding
sites
RNA DNA
Reverse
transcription Transcription
Integration of provirus
DNA into host DNA
Translation
Cell
membrane
Completed
HIV particle
Maturation
Budding
Viral
assembly
Protein
cleavage
gp41 gp120
RNA s
e
Protease
Integrase
Provirus
(circular
structure)
Protease
Inhibitors
work here
NRTI’s &
NNRTI’s
work here
Fusion
inhibitors
work here
CD4
Cell
HIV
Particle

HIV 417
Summary
• HIV is a retrovirus which kills CD4 cells and so weakens the
immune system
• Rapid replication of HIV causes genetic diversity of the virus
• Knowledge of the HIV structure is important in knowing the
targets of ARV drugs
• HIV enzymes are mostly the targets of ARV drugs
• ARV‘s do not cure HIV

HIV 418
HIV
Classification
• HIV-1 is further classified into two groups
designated -M and O
• M( Major)-which is further subdivided into
subtypes or classes designated A-K
• O( Out-lier) designated subtype O.
• This classification is based on the
genomic(DNA) sequence .

HIV 419
HIV
Transmission
• There are three well recognized modes of
transmission:
• 1.Sexual
• 2.Direct inoculation: Blood transfusion or
sharing sharp instruments
• 3.Mother to child

HIV 420
HIV
Transmission
• Direct inoculation.
• This is as a result of transfusion of
contaminated blood,blood products.
• Reuse of contaminated needles,syringes

HIV421
Transmission cont.
Transmission route %
Sexual intercourse 70-80
Mother-to-child-transmission 5-10
Blood transfusion 3-5
Injecting drug use 5-10
Health care – eg: needle stick injury <0.01

HIV 422
HIV
Transmission
• Sexual:
• This is the commonest mode of transmission accounting for
over 75% of all the HIV transmissions.
• Any form of sexual intercourse where there is exchange of
body fluids(heterosexual-male-female),(homosexual-male-
male),(lesbian-female-female).
• Use of contaminated hospital instruments(dialysis
machines).
• Can also occur accidentally among health care workers
through needle stick injuries and other injuries.

HIV 423
HIV
Transmission
• Mother to child transmission:
• This occurs in about 20%-40% of children
born to HIV positive mothers
• In total, mother to child transmission accounts
for about 25% of the HIV cases.
• This mode of transmission is referred to as
vertical transmission

HIV 424
Modes of transmission in pictures

HIV 425
HIV-
Pathogenesis
Natural progression of HIV infection

HIV 426
Cells of the immune system
• Found in blood and tissues
• In blood mostly are white blood cells (WBC)
• Macrophages act as clearing cells
• Neutrophils attack bacteria
• Eosinophils attack worms (and allergies)
• B-lymphocytes make antibodies
• T-lymphocytes
» T helper cells helps in communication of immune cells
» T killer cells are able to destroy infected cells

HIV 428
How HIV affects immune system
• HIV attaches to cells of the immune systems with specials surface markers called CD4
receptors
• The following immune cells have CD4 receptors
• T-Lymphocytes – CD4 Cells
• Macrophages
• Monocytes
• Dendritic cells
• HIV infection of CD4 cells causes cell death and affects their function
• Reduction in the CD4 cell number and the effects on their function reduces the capacity of
the body to fight diseases.
• Individuals with HIV infections are therefore susceptible to many infections especially at late
stage of HIV infections

HIV 429
Host immune response during HIV
infection
• Primary HIV Infection
• On first exposure, there is a 2-4 week period of intense
viral replication before onset of an immune response
and clinical illness
• Acute illness lasts from 1-2 weeks,
• Clinical manifestations resolve as antibodies to virus
become detectable in patient‘s serum
• Patients then enter a stage of asymptomatic infection
lasting from months to many years

HIV 430
Signs and Symptoms of HIV Infection
Some of the symptoms that people with HIV may have include:
• An unexplained loss of weight of >10% of body weight
• Diarrhea lasting for several weeks
• A white coating on the tongue (thrush/oral candidiasis)
• Enlarged or sore glands (lymph nodes) in the neck, armpits,
and/or groin, as well as generalized swollen glands
• A cough that persists for more than one month
• Persistent fever and/or night sweats
• In women, persistent vaginal candidiasis (yeast
infection)
* Memory loss * skin rash * profuse sweating

HIV 431
Characteristics of Sero-conversion
• 2 to 4 weeks after infection
• Virus disseminated via blood to CNS
and lymphoid tissue
• Rapid rates of viral replication
• Virus trapped in lymph nodes
• Immune response and antibody
production against HIV
• May be characterized by rash, fever,
fatigue and lymphadenopathy
• Non-specific, so rarely diagnosed
-in blood†
*
RNA †whole virus
CD4
Viral load
-in plasma*
Time
Viral Load
CD4 Count
Seroconversion

HIV 432
• Can last from 2 to 15 years – range
mainly due to genetic differences in
patient
• Virus replicates in lymphoid tissue,
CD4 cells at high rates
• CD4 levels gradually decline
• Immunity gradually weakens
• Patients remain asymptomatic
• Patients are infectious
Characteristics of Clinically
Asymptomatic Phase
-in blood†
*
RNA †whole virus
CD4
Viral load
-in plasma*Viral Load
CD4 Count
Asymptomatic
Phase

HIV 433
Characteristics of Symptomatic
Phase (progression to AIDS)• Approximately 10 to 12 years after
infection
• Increased demands on immune system
• Production of CD4 cells cannot match
destruction, immune system fails
• Viral load reaches extremely high levels
• Increased risk of opportunistic infections
and tumors
• Progression to AIDS
-in blood†
*
RNA †whole virus
CD4
Viral load
-in plasma*
Symptomatic
CD4 Count
Viral Load

HIV 434
Bacterial skin infections
Shingles
Thrush (mouth & tongue)
Severe atheletes foot
Oral hairy leukoplakia
Tuberculosis
PCP
Cryptococcal meningitis
Toxoplasmosis
Herpes simplex infections
Histoplasmosis
100
250
500
7 9
CD4cellcount(cells/mm3)
10
Cytomegalovirus infections
Mycobacterium avium
Complex infections
Opportunistic Infections
During Disease Progression
3-15 years
Time after infection

HIV435
WHO Classification
Clinical Stages I & II
Clinical stage Selected symptoms Performance scale
Stage I 1. Asymptomatic
2. Persistent generalized lymphadenopathy
3. Acute retroviral infection
scale 1:
Asymptomatic,
normal activity
Stage II 1. Weight loss but <10% of body weight
2. Minor mucocutaneous manifestations
(seborrhoeic dermatitis, priurigo, fungal
infections, recurrent oral ulcerations, angular
cheilitis)
3. Herpes zoster, within last 5 years
4. Recurrent upper respiratory tract infections
(eg: bacterial sinusitis)
And/or performance
scale 2:
Symptomatic with
normal activity

HIV436
WHO classification
Clinical Stage III
Clinical stage Selected symptoms Performance scale
Stage III 1. Weight loss: >10% of body weight
2. Unexplained chronic diarrhoea, >1 month
3. Unexplained prolonged fever >1 month
4. Oral candidiasis (thrush)
5. Vulvovaginal candidiasis, chronic (>1 month
or poorly responsive to therapy)
6. Oral hairy leucoplakia
7. Pulmonary tuberculosis, within past year
8. Severe bacterial infections (eg:
pneumonia, pyomyositis)
And/or
performance
scale 3:
Bed-ridden but for
<50% of the day
during the last month

HIV437
WHO Classification
Clinical Stage IV
Clinical
Stage
Selected symptoms Performance Scale
Stage IV 1. HIV wasting syndrome (8 with 9 or 10 of WHO 3)
2. Pneumocystis carinii pneumonia (PCP)
3. Toxoplasmosis of the brain
4. Cryptosporidiosis, with diarrhoea >1 month
5. Cryptococcosis (extrapulmonary)
6. Cytomegalovirus (CMV) disease of an organ (other than liver,
spleen, or lymph nodes)
7. Herpes simplex virus (HSV) infection, mucocutaneous >1 month,
8. Progressive multifocal leukoencephalopathy
9. Any disseminated endemic mycosis (eg: histoplasmosis)
10. Candidiasis of the oesophagus or airways
11. Atypical mycobacteriosis, disseminated
12. Non-typhoid salmonella septicaemia
13. Extrapulmonary tuberculosis
14. Lymphoma
15. Kaposi‘s sarcoma (KS)
16. HIV encephalopathy
17. Invasive cervical carcinoma
And/or
performance
scale 4:
Bed-ridden for >50% of
the day during the last
month

HIV 438
Use of staging
• For deciding when to initiate ART
• Cannot be used for:
– Follow up
– Monitoring purposes

HIV 439
Summary
• HIV targets the CD4 cell
• Reduction in number of CD4 cells destroys
the immune system of the host
• Patients with low CD4 cells are susceptible to
many infections
• WHO Classification can be used to Stage HIV
Disease

HIV 440
HIV
Pathogenesis
• The stages of HIV infection of cells:
• viral binding
• Un-coating
• transcription, integration, and translation
• assembly and release of viral
particles(virions).

HIV 441
NATURAL HISTORY OF HIV
INFECTION
• Stage1-Acute infection-this is the point of
sero-conversion.It is associated with non-
specific signs and symptoms( fever, general
malaise,generalized lymphadenopathy)
• Stage II-Asymptomatic infection-begins after
the signs and symptoms of stage I have
resolved.This stage may last 8-10 years.(
Incubation period.

HIV 442
NATURAL HISTORY OF HIV
INFECTION
• Stage III- This is the symptomatic period with
constitutional diseases -- leading to an AIDS
diagnosis.
• HIV positive plus(wasting,thrush,hairy
leukoplakia,dermatitis,chronic
diarrhoea,PTB,Kaposi sarcoma,recurrent
pneumonia) defines an AIDS diagnosis.

HIV 443
Basic facts
• AIDS is now the number one killer of persons aged 25 up to 44 years in the world
• Over 35 million are infected
• 11 persons are infected per second
• In Africa the infection rate is 8,600 cases per day
• Over 20 million are already dead
• More than 15 million have been orphaned in Sub-Saharan Africa
• Prevalence reached 40% in some countries
• More than 800 persons die every day in Some African countries
• 50% of the hospital beds are occupied in several countries in Sub-Saharan Africa
• 65% of HIV/AIDS Cases are currently in Africa with 11% of world population
• In SL prevalence is still low but increasing year after a year

HIV 444
Preventive measures
• ABCDE
• Safe blood transfusion
• Increased awareness
• Sterilized medical equipment
• Universal precautions
• Reduction of MTCT
• Stop sharing sharp instruments
• Stop drug addictions
• Reduction of Stigma and discrimination

HIV 445
Prevention Verses cont.
Oh ye who believe! Ye are forbidden to inherit women
against their will. Nor should you treat them with
harshness, that you may take away part of the dower
ye have given them, except where they have been
guilty of open lewdness; on the contrary live with
them on a footing of kindness and equity. If ye take a
dislike to them it may be that you dislike a thing, and
Allah brings about through it a great deal of good.
(Quran 4: 19)
They ask thy instruction concerning the women.
Say: Allah doth instruct you about them: and
(remember) what hath been rehearsed unto you in
the Book, concerning the orphans of women to
whom ye give not the portion prescribed, and yet
whom ye desire to marry, as also concerning the
children who are weak and oppressed; that ye stand
firm for justice to orphans. There is not a good thing
which ye do, but Allah is well-acquainted therewith.
(Quran 4: 127)

HIV 446
Prevention cont.Say: "Not equal are things that are bad and
things that are good even though the
abundance of the bad may dazzle thee; so
fear Allah O ye that understand! that (so) ye
may prosper."
Surat Al Ma‘idah: 100
Say: "Come, I will rehearse what Allah hath
(really) prohibited you from": join not anything
as equal with Him; be good to your parents;
kill not your children on a plea of want - We
provide sustenance for you and for them -
come not nigh to shameful deeds, whether
open or secret; take not life, which Allah hath
made sacred, except by way of justice and
law: thus doth He command you, that ye may
learn wisdom. (Quran 6:151)
Surat Al An‘àm: 151
O ye Children of Adam! Let not Satan seduce
you, in the same manner as he got your
parents out of the Garden, stripping them of
their raiment, to expose their shame: for he
and his tribe watch you from a position where
ye cannot see them: We made the Evil Ones
friends (only) to those without Faith. (Quran
Surat Al A‘ràf : 27

HIV 447
HIV& Islam:
‫الجنسٌة‬ ‫العالقة‬ ‫تمجٌد‬
•‫إلٌها‬ ‫لتسكنوا‬ ً‫ا‬‫ازؤاج‬ ‫أنفسكم‬ ‫من‬ ‫لكم‬ ‫خلق‬ ‫ان‬ ‫آٌاته‬ ‫ومن‬
‫لقوم‬ ‫آلٌات‬ ‫ذلك‬ ً‫ف‬ ‫إن‬ ‫ؤرحمة‬ ‫مؤدة‬ ‫بٌنكم‬ ‫وجعل‬
‫ٌتفكرون‬]‫؟؟‬]‫الروم‬:21. [
•‫كلها‬ ‫األزواج‬ ‫خلق‬ ‫الذي‬ ‫سبحان‬:‫تنبت‬ ‫مما‬‫ومن‬ ،‫األرض‬
‫ٌعلمون‬ ‫ال‬ ‫ومما‬ ،‫انفسهم‬

HIV 448
HIV&AIDS cont.
•‫لها‬ ‫التحدٌد‬
•‫ملكت‬ ‫ما‬ ‫أو‬ ‫أزواجهم‬ ‫على‬ ‫إال‬ ، ‫حافظون‬ ‫لفروجهم‬ ‫هم‬ ‫والذٌن‬
‫هم‬ ‫فإولئك‬ ‫ذلك‬ ‫وراء‬ ً‫ابتغ‬ ‫،فمن‬ ‫ملومٌن‬ ‫غٌر‬ ‫فإنهم‬ ‫أٌمانهم‬
‫العادون‬] ]‫المؤمنون‬5-7. [
•‫سبٌال‬ ‫وساء‬ ‫فاحشة‬ ‫كان‬ ‫إنة‬ ‫الزنى‬ ‫تفربوا‬ ‫وال‬] "‫اإلسراء‬:
32. [
•‫تقربوا‬ ‫ؤال‬‫منها‬ ‫ظهر‬ ‫ما‬ ‫الفواحش‬‫بطن‬ ‫وما‬]،]‫األنعام‬:
151[

HIV 449
HIV&AIDS cont.
•‫الشٌطان‬ ‫عمل‬ ‫من‬ ‫رجس‬ ‫واالزالم‬ ‫واألنصاب‬ ‫والمٌسر‬ ‫الخمر‬ ‫إنما‬
‫تفلحون‬ ‫لعلكم‬ ‫فاجتنبوه‬.‫بٌنكم‬ ‫ٌوقع‬ ‫أن‬ ‫الشٌطان‬ ‫ٌرٌد‬ ‫إنما‬
‫وعن‬ ‫هللا‬ ‫ذكر‬ ‫عن‬ ‫وٌصدكم‬ ‫والمٌسر‬ ‫الخمر‬ ‫فى‬ ‫والبغضاء‬ ‫العداوة‬
‫؟‬ ‫منتهون‬ ‫انتم‬ ‫فهل‬ ‫الصالة‬!
•‫وستون‬ ‫بضع‬ ‫اإلٌمان‬-‫شهادة‬ ‫أعالها‬ ،‫شعبة‬ ‫وسبعون‬ ‫بضع‬ ‫أو‬
‫والحٌاء‬ ،‫الطرٌق‬ ‫عن‬ ‫األذى‬ ‫إماطة‬ ‫وأدناها‬ ‫هللا‬ ‫إال‬ ‫له‬ ‫إ‬ ‫ال‬ ‫أن‬
‫االٌمان‬ ‫من‬ ‫شعبة‬

HIV 450
HIV&Islam
•‫خالف‬ ‫لمن‬ ‫الزاجرة‬ ‫العقوبة‬
•‫واحد‬ ‫كل‬ ‫فاجلدوا‬ ً‫ؤالزان‬ ‫الزانٌة‬‫تاخذكم‬ ‫ؤال‬ ،‫جلدة‬ ‫مائة‬ ‫منهما‬
،‫اآلخر‬ ‫والٌوم‬ ‫ٌاهلل‬ ‫تؤمنون‬ ‫كنتم‬ ‫إن‬ ‫هللا‬ ‫دٌن‬ ‫فى‬ ‫رأفة‬ ‫بهما‬
‫ولٌشهد‬‫المؤمٌٌن‬ ‫من‬ ‫طائفة‬ ‫عذابهما‬]‫النور‬:2. [

HIV 451
Hiv& Islam cont.
‫يغضىامه‬ ‫نهمؤمىيه‬ ‫قم‬‫بما‬ ‫خبيس‬ ‫هللا‬ ‫إن‬ ،‫نهم‬ ‫أشكى‬ ‫ذنك‬ ،‫فسوجهم‬ ‫ويحفظىا‬ ،‫ابصازهم‬
‫يصىعىن‬.‫إأل‬ ‫شيىحهه‬ ‫يبديه‬ ‫وال‬ ‫فسوجهه‬ ‫ويحفظه‬ ‫أبصازهه‬ ‫مه‬ ‫يغضضه‬ ‫نهمؤمىات‬ ‫وقم‬
‫أو‬ ‫إخىاوهه‬ ‫بىي‬ ‫أو‬ ‫إخىاوهه‬ ‫أو‬ ‫بعىنحهه‬ ‫أبىاء‬ ‫أو‬ ‫أبىائهه‬ ‫أو‬ ‫بعىنحهه‬ ‫آباء‬ ‫أو‬ ‫آبائهه‬ ‫أو‬ ‫نبعىنحهه‬
‫انطفم‬ ‫أو‬ ‫انسجال‬ ‫مه‬ ‫اإلزبة‬ ‫أوني‬ ‫غيس‬ ‫انحابعيه‬ ‫أو‬ ‫أيماوهه‬ ‫مهكث‬ ‫ما‬ ‫أو‬ ‫وسائهه‬ ‫أو‬ ‫أخىاجهه‬ ‫بىي‬
‫وجىبىا‬ ، ‫شيىحهه‬ ‫مه‬ ‫يخفيه‬ ‫ما‬ ‫نيعهم‬ ‫بأزجههه‬ ‫واليضسبه‬ ‫انىساء‬ ‫عىزات‬ ‫عهى‬ ‫يظهسوا‬ ‫نم‬ ‫انريه‬
‫جفهحىن‬ ‫نعهكم‬ ‫انمؤمىىن‬ ‫أيها‬ ً‫ا‬‫جميع‬ ‫هللا‬ ‫إنى‬[ [‫انىىز‬:30‫ـ‬31. ]

HIV 452
‫انريه‬ ‫ايها‬ ‫يا‬ً‫ا‬‫بيىج‬ ‫جدخهىا‬ ‫آل‬ ‫آمىىا‬‫جسحاوسىا‬ ‫ححى‬ ‫بيىجكم‬ ‫غيس‬
‫جركسون‬ ‫نعهكم‬ ‫نكم‬ ‫خيس‬ ‫ذنكم‬ ، ‫أههها‬ ‫عهى‬ ‫وجسهمىا‬.‫ججدوا‬ ‫نم‬ ‫فأن‬
‫ازجعىا‬ ‫نكم‬ ‫قيم‬ ‫وإن‬ ، ‫نكم‬ ‫يؤذن‬ ‫ححي‬ ‫جدخهىها‬ ‫فال‬ ً‫ا‬‫أحد‬ ‫فيها‬
‫هى‬ ‫فازجعىا‬‫عهيم‬ ‫جعمهىن‬ ‫بما‬ ‫وهللا‬ ، ‫نكم‬ ‫اشكى‬[[‫انىىز‬:27-
28. ]

HIV 453
HIV&Islam
•‫فقال‬":‫السثسباب‬ ‫معشر‬ ‫ٌا‬!‫أغض‬ ‫فإنه‬ ،‫فلٌتزوج‬ ‫الباءة‬ ‫منكم‬ ‫استطاع‬ ‫من‬
‫للبصر‬‫له‬ ‫فإنه‬ ‫بالصوم‬ ‫فعلٌه‬ ‫ٌستطع‬ ‫لم‬ ‫ومن‬ ‫؛‬ ‫للفرج‬ ‫وأحفظ‬‫وجاء‬―]‫متفق‬ ‫حدٌث‬
‫هللا‬ ‫عبد‬ ‫رواٌة‬ ‫من‬ ‫علٌه‬‫عنه‬ ‫هللا‬ ‫رضى‬ ‫مسعود‬ ‫ابن‬.‫على‬ ‫القدرة‬ ‫الباءة‬ ‫ومعنى‬
‫الجنسٌة‬ ‫للشهوة‬ ‫الكابح‬ ‫والوجاء‬ ،‫الزواج‬‫الجامحة‬. "
•‫وإمائكم‬ ‫عبادكم‬ ‫من‬ ‫ؤالصالحٌن‬ ‫منكم‬ ‫األٌامى‬ ‫وانكحوا‬!‫ٌغنهم‬ ‫فقراء‬ ‫ٌكونوا‬ ‫إن‬‫هللا‬
‫علٌم‬ ‫واسع‬ ‫وهللا‬ ‫فضله‬ ‫من‬*‫من‬ ‫هللا‬ ‫ٌغنٌهم‬ ‫حتى‬ ً‫ا‬‫نكاح‬ ‫الٌجدون‬ ‫الذٌن‬ ‫ولٌستعفف‬
‫فضله‬…] ]‫النور‬:32-33[
•‫عونهم‬ ‫هللا‬ ‫على‬ ‫حق‬ ‫ثالثة‬:،‫األداء‬ ‫ٌرٌد‬ ‫الذي‬ ‫والمكاتب‬ ،‫العفاف‬ ‫ٌرٌد‬ ‫الذي‬ ‫الناكح‬
‫هللا‬ ‫سبٌل‬ ً‫ف‬ ‫والمجاهد‬( .ً‫والنسائ‬ ‫الترمذي‬ ‫رواه‬ ‫صحٌح‬ ‫حدٌث‬.)

HIV 454
HIV&Islam
•‫الزاجرة‬ ‫العقوبات‬
•‫وال‬ ، ‫جلدة‬ ‫مائة‬ ‫منهما‬ ‫واحد‬ ‫كل‬ ‫فاجلدوا‬ ً‫والزان‬ ‫الزانٌة‬‫تاخذكم‬
‫بهما‬‫باهلل‬ ‫تؤمنون‬ ‫كنتم‬ ‫إن‬ ‫هللا‬ ‫دٌن‬ ً‫ف‬ ‫رأفة‬،‫اآلخر‬ ‫والٌوم‬
‫المؤمنٌن‬ ‫من‬ ‫طائفة‬ ‫عذابهما‬ ‫ولٌشهد‬] ]‫النور‬:2[.

HIV 455
HIV&Islam
•‫اإلنسان‬ ‫وحقوق‬ ‫الحرٌة‬ ‫ومفهوم‬ ‫الدٌنٌة‬ ‫التعالٌم‬
•‫عقد‬ ‫قبل‬ ً‫ت‬ ً‫س‬ ً‫ف‬ ، ‫الضررٌنن‬ ‫أخف‬ ،‫ضرار‬ ‫وال‬ ‫ضرر‬ ‫ال‬
‫الزواج؟‬
•‫والمال؟‬ ‫النفس‬ ‫على‬ ‫األذى‬:
•‫ورسوله‬ ‫هللا‬ ‫ٌحاربون‬ ‫الذٌن‬ ‫جزاء‬ ‫انما‬‫األرض‬ ً‫ف‬ ‫وٌسعون‬ ،
‫فسادا‬‫من‬ ‫وأرجلهم‬ ‫أٌدٌهم‬ ‫تقطع‬ ‫أو‬ ،‫ٌصلبوا‬ ‫أو‬ ‫ٌقتلوا‬ ‫أن‬ ،
ً‫ف‬ ‫ولهم‬ ،‫الدنٌا‬ ً‫ف‬ ‫خزي‬ ‫لهم‬ ‫ذلك‬ ،‫األرض‬ ‫من‬ ‫ٌنفوا‬ ‫أو‬ ،‫خالف‬
‫عظٌم‬ ‫عذاب‬ ‫اآلخرة‬( .33‫المائدة‬)

HIV 456
HIV&Islam
•‫القتل‬ ‫أكبر‬ ‫أٌهما‬ ‫لماذا؟‬ ‫الحظر‬ ‫الطبٌة؟‬ ‫واالستخدامات‬ ‫العازل‬
‫الزنا؟‬ ‫أم‬
•‫العازل؟‬ ‫من‬ ً‫االسالم‬ ‫العالم‬ ‫موقف‬ ‫هو‬ ‫ما‬
•‫قل‬:‫الرزق‬ ‫من‬ ‫والطٌبات‬ ‫لعبادة‬ ‫أخرج‬ ‫التى‬ ‫هللا‬ ‫زٌنة‬ ‫حرم‬ ‫من‬
‫؟‬!‫قل‬:‫؛‬ ‫القٌامة‬ ‫ٌوم‬ ‫خالصة‬ ‫الدنٌا‬ ‫الحٌاة‬ ‫فى‬ ‫آمنوا‬ ‫للذٌن‬ ً‫ه‬
‫ٌعلمون‬ ‫لقوم‬ ‫اآلٌات‬ ‫نفصل‬ ‫كذلك‬!‫قل‬:‫الفواحش‬ ً‫رب‬ ‫حرم‬ ‫إنما‬
‫وأن‬ ، ‫الحق‬ ‫بغٌر‬ ً‫والبغ‬ ، ‫واألثم‬ ، ‫ـ‬ ‫بطن‬ ‫وما‬ ‫منه‬ ‫ظهر‬ ‫ما‬ ‫ـ‬
‫ما‬ ‫هللا‬ ‫على‬ ‫تقولوا‬ ‫وأن‬ ، ‫سلطانا‬ ‫به‬ ‫ٌنزل‬ ‫لم‬ ‫ما‬ ‫باهلل‬ ‫تشركوا‬
‫التعلمون‬]‫األعراف‬:32‫ـ‬33. [

HIV 457
HIV& Islam cont
•‫ٌنكحها‬ ‫ال‬ ‫والزانٌة‬ ،‫مشركة‬ ‫أو‬ ‫زانٌة‬ ‫اال‬ ‫ٌنكح‬ ‫ال‬ ً‫الزان‬
‫المؤمنٌن‬ ‫على‬ ‫ذالك‬ ‫وحرم‬ ‫مشرك‬ ‫أو‬ ‫زان‬ ‫اال‬(‫النور‬3)

HIV 458
HIV&Islam
•‫له‬ ‫ذنب‬ ‫ال‬ ‫كمن‬ ‫الذنب‬ ‫من‬ ‫التائب‬.‫الغامدٌة‬ ‫والمرأ‬ ‫مالك‬ ‫بن‬ ‫ماعز‬ ‫قصة‬
•‫التوابون‬ ‫الخطائٌن‬ ‫وخٌر‬ ،‫خطائٌن‬ ‫كلكم‬(‫صحٌح‬ ‫حدٌث‬)
•‫منهم‬ ً‫ا‬‫خٌر‬ ‫ٌكونوا‬ ‫ان‬ ‫عسى‬ ‫قوم‬ ‫من‬ ‫قوم‬ ‫الٌسخر‬ ‫آمنوا‬ ‫الذٌن‬ ‫اٌها‬ ‫ٌا‬‫من‬ ‫والنساء‬
‫باألبقاب‬ ‫تنابزوا‬ ‫وال‬ ‫أنفسكم‬ ‫والتلمزوا‬ ، ‫منهن‬ ‫خٌرا‬ ‫ٌكن‬ ‫ان‬ ً‫عس‬ ‫نساء‬
]‫الحجرات‬:11.[
•‫باشفاء‬ ‫لهم‬ ‫والدعوة‬ ً‫والسع‬ ، ‫الٌهم‬ ‫والزٌارة‬ ، ‫المسلمٌن‬ ‫بمرضى‬ ‫العناٌة‬.

HIV 459
Verses for Stigma & Discrimination Cont.
It is He Who giveth life and who
taketh it, and to Him shall ye all be
brought back.
(Quran 10: 56)(Quran 7:199)
Surat Al-A‘ràf: 199
Say: "I have no power over any harm or
profit to myself except as Allah willeth. To
every People is a term appointed: when
their term is reached, not an hour can
they cause delay, nor (an hour) can they
advance (it in anticipation)."(Quran 10:
49)
Surat Yunus: 49
Hold to forgiveness;
Command what is right; but
turn away from the ignorant.
Surat Yunus: 56

HIV 460
Somaliland HIV/AIDS Strategies VS Action plans
• 1. Strengthen advocacy,
resource mobilization and
policy formulation:
• Develop a strategy for
integration of HIV/AIDS in
leadership development
programmes
• Develop enabling policies to
guide the HIV/AIDS response.
• Policy on discrimination
against people infected and
affected by HIV/AIDS.
• 2. Increased awareness and
community mobilization.
• Promote Mobilization through
IEC (Broadcasting, Training
and community based
activities).
• Skill development for
teachers in HIV/AIDS
education
• Revision of curriculum
(Provide technical assistance
to MOE)

HIV 461
S/L strategies Vs actions
• 3.Increased availability, quality
and accessibility of safe
services.
• Review and strengthen capacity
of health facilities for
increased/improved accessibility
and availability of safe/quality
services
• Strengthening of STI
management
• Set up guidelines of improved
blood transfusion services
• Set up M&E for HIV/AIDS/STIs
• 4.Promotion of comprehensive
prevention and treatment
• Establish HIV voluntary
counseling and testing.
• Ensure availability of diagnostic
supplies for HIV/AIDS and STIs
testing.
• Draft guidelines for ART/PMTCT
• Support upgrading of laboratory
services

HIV 462
S/L strategies Vs Action plans
cont.• Reduction and mitigation of
negative impact of HIV/AIDS
epidemic
• Provide targeted support to
people living with HIV/AIDS
• Set up community home base
care.
• Adapt and translate healthy
nutrition booklet.
• 6.Strengthening response
management and
implementation capacities
• Strengthen the imple-
mentation capacity of partners
• Strengthen Somaliland
national commission &
secretariat
• Strengthen the capacity of the
national commission and
partners to carry out core
coordination functions.

HIV 463
Advocacy continued
Let there arise out of you a band
of people inviting to all that is
good, enjoining what is right, and
forbidding what is wrong: they
are the ones to attain felicity.
O ye who believe! Take not into
your intimacy those outside your
ranks: they will not fail to corrupt
you. They only desire your ruin:
rank hatred has already appeared
from their mouths: what their
hearts conceal is far worse. We
have made plain to you the
Signs, if ye have wisdom.
Surat Al-Imran: 118
Surat Al-Imran:104

HIV 464
Advocacy cont.
If they charge thee with falsehood, say:
"My work to me, and yours to you! Ye
are free from responsibility for what I do
and I for what ye do!"
(Quran 10:41)
Surat Yunus: 41
O mankind! There hath come to you a
direction from your Lord and a healing
for the (diseases) in your hearts, and for
those who believe, a Guidance and a
Mercy.
(Quran 10:57)
Surat Yunus: 57

HIV 465
Supportive Policy & Social
environment
Adults and
children
Affected and or
infected with
HIV/AIDS
HIV/AIDS
Clinical care: VCT,PMTCT,
Management of STIs & OIs,
palliative care, ART and
nutritional support
Psychosocial
support:
Counseling, orphan
care, community
Support services &
spiritual supports
Human rights and legal
support:
Stigma & discrimination
reduction,
PLWHA participation, succession
Planning
Socioeconomic
Support:
Material support,
economic and
food security
P r e v e n t i o n
IPTCS

HIV 466
Infection Control in
HIV/AIDS and PEP
WHO Somalia/Somaliland HIV/AIDS Team

HIV 467
Accidental blood exposure (ABE)
Risk of transmission after ABE
30 % for HBV, if percutaneous accident
3 % for HCV
0.3 –0.4% for HIV

HIV 468
Accidental blood exposure (ABE)
IMPORTANT TO NOTE
• Prevention is possible
• Respect of universal precautions
• Reduction of seroconversion risk:
ARV
• Systematic reporting ABE

HIV 469
The Universal Precautions
Care with venepuncture:
NB the cause of most health care worker
infections
– Always dispose of needle immediately post
venepuncture
– DO NOT recap needles after use
– Always have a sharps container next to
you
– Never leave sharps for another to dispose

HIV 470
Universal precautions contd
• wear gloves on cleaning up spills of
body fluids
• clean spills with detergent / dilute
solution of bleach as viro-cidal
• wear masks and eye protection when
splash injuries are possible – at lumbar
puncture, skin biopsy et cetera

HIV 474
Don‟t leave a mess behind

HIV 475
PEP initial steps
• Determine the extent of the exposure
Superficial exposition: Minor injury.
Severe exposition: exposure involving membrane,
non-intact skin and percutaneous injury.
• Determine HIV status of the recipient/HW.
• Determine HIV status of patient source
Patient source known HIV negative: no risk
Patient source known HIV positive: risk
Patient source status not known: risk

HIV 476
Risk Exposure classification:
1. High risks
2. Low risk

HIV 477
Low Risk Exposure
• Solid needle, superficial exposure
on intact skin up to 0.04%
• Small volume (drops of blood) on
mucous membrane or non-intact
skin
• Source is asymptomatic

HIV 478
High Risk Exposure
• Skin exposures
Source is symptomatic, acute sero-
conversion, high VL, Hollow bore needle stick
(0.5% seroconvert
Large bore needle, deep injury, visible blood on
device, needle in patient artery/vein.
Large volume (major blood splash on mucous
membrane or non-intact skin
Laceration with blood stained instrument
Conjunctival splash with HIV infected fluid

HIV 479
Post Exposure Prophylaxis (PEP)
If a healthcare worker has a significant exposure:
– commence ARVs immediately (with in 72 hrs prefer >24hrs)
– use two or three agents for 4 weeks
– avoid agents with symptomatic side effects, as workers will
stop taking them e.g. AZT & efavirenz
– d4T + 3TC +/- Kaletra are generally tolerable
– avoid nevirapine (except perhaps one initial dose – as
NNRTIs are immediately active), as rare acute
hypersensitivity reactions (+/- acute hepatic necrosis) more
common in those with intact immune systems

HIV 480
Post Exposure Prophylaxis contn
If a health center has no d4T then AZT
can be used
Women of childbearing age must be
offered a pregnancy test prior to
starting PEP.
In case of pregnancy don’t use
Efavirenz

HIV 481
Post Exposure Prophylaxis (PEP)
follow-up
– Counseling and support to HW
– Explain the side effects of the ARV
drugs
– Hiv atibody testing at 3months and 6
months
– Transminases
– Adopt safe sexual practices during
follow-up

HIV 482
Conclusion
• Universal precaution should be applied in all
procedures
• Ensure safety of HW in the health care settings
• Promote the use of safe equipment and procedures
• Safe and proper disposal of sharps and other wastes
• Promotion of Hepatitis B vaccination for HW
• Provide PEP TREATMENT TIMELY

HIV 483
Thank you for your
attention

Chapter:12
Nutrition
The science of Nutrition:
• Nutrition studies the interaction between the
individual and the environment mediated by
food
• Study of food in relation to man, and study of
man in relation to food

Human Nutrition
• Human Nutrition is a scientific discipline,
concerned with the access and utilization of
foods and nutrients for life, health, growth,
development, and well- being

The science of Nutrition:
Areas of Study
– Food production
– Diet composition (including non-nutritive
substances)
– Food intake, appetite, food preferences
– Digestion and absorption of nutrients
– Intermediary metabolism, nutritional biochemistry

The Science of Nutrition -
Areas of Study
– Biological actions of essential nutrients
– Nutrient requirements in individuals and
populations
– Heath effects of nutrient deficiencies and
excesses
– Long-term effects of diet constituents
– Therapeutic and preventive effects of foods

Nutrition…
• Dietetics
– Science/ art of applying the principles of nutrition
in feeding
– Older subject, practiced by Hippocrates 460-360
BC.

Public Health Nutrition
• Public Health Nutrition focuses on issues that
affect the whole population rather than the
specific dietary needs of individuals

Malnutrition
• A pathological state resulting from a relative
or absolute deficiency or excess of one or
more essential nutrients, this state being
clinically manifested or detected only by
biochemical, anthropometric or physiological
tests

Forms of Malnutrition
• Under nutrition
– Pathological state resulting from the consumption
of an inadequate quality/ quantity over an
extended period of time
• Over-nutrition
– Pathological state resulting from the consumption
of an excess quantity of food, and hence an
energy excess, over an extended period of time

Prevalence and number of
children with chronic
undernutrition in developing
regions (1969-1992)

Estimated prevalence and number of
underweight children 0−5 years old
1990−2005
494

Global Distribution of Malnutrition

Trends of malnutrition in Sub-
Saharan Africa (1983-2001)

Global Distribution of
Malnutrition

Global Distribution of
Malnutrition…

Nutrition and Development
• Poor nutrition perpetuates the cycle of
poverty and malnutrition through 3 main
routes -
 direct losses in productivity from poor
physical status and losses caused by
disease
 indirect losses from poor cognitive

Nutrition, economic growth,
and markets
– The income–malnutrition relationship is
modest
– When gross national product (GNP) per
capita in developing countries doubles,
nutrition does improve but the changes in
underweight rates are much more
modest— from 32 to 23 percent
– it is estimated that sustained per capita

Markets are failing
– Market forces do not suffice to improve
nutrition; public investment is necessary
– Informational asymmetries of two kinds:
• People cannot tell when their children are
becoming malnourished b/c healthy growth
rates, can't be detected with the
naked/‗untrained‘ eye

Nutrition and income poverty
– Undernutrition and micronutrient
malnutrition are themselves direct
indicators of poverty, in the broader
definition of the term that includes human
development
– The prevalence of malnutrition is often two
or three times - and sometimes many times
- higher among the poorest income quintile
than among the highest quintile
• This means that improving nutrition is pro-poor

Nutrition and Human Rights
– The 1948 Universal Declaration of Human
Rights established adequate health,
including adequate food, as a basic human
right
– The right to adequate nutrition is also
enshrined in the constitutions of many
countries—for example, those of Ethiopia,
Guatemala, India, Peru, and South Africa

The Know-How for Improving
Nutrition
– we know what to do to improve nutrition and
the expected rates of returns from investing
in nutrition are high
– Compared with many possible development
investments, including trade reform and
private sector deregulation, malaria
eradication, and water and sanitation, the
provision of micronutrients was identified as
the second best opportunity for meeting the
world‘s development challenges

The Know-How for Improving
Nutrition…
– The final argument for investing in nutrition is that
there are tried and tested models and
experiences for reducing most forms of
malnutrition - that have not been adequately
exploited and scaled up
– In some exceptional countries, nutrition programs
have virtually universal coverage (Chile, Costa

Nutrition and Development…
• Nutrition and economic development have a two-way
relationship
• MDGs ; focus the efforts of the world community on
achieving significant, measurable improvements in
people's lives
• The first seven goals are mutually reinforcing and are
directed at reducing poverty in all its forms. The last goal -
- global partnership for development -- is about the means
to achieve the first seven.

Millennium Development Goals
1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality
4. Reduce child mortality
5. Improve maternal survival
6. Combat HIV/AIDS, malaria & other diseases
7. Ensure environmental sustainability
8. Develop a Global Partnership for

Goal 1: Eradicate Extreme
Poverty and Hunger• Target 1: Halve, between 1990 and 2015,
the proportion of people whose income is
less than $1 (0.80 Euros) a day
• Target 2: Halve, between 1990 and 2015,
the proportion of people who suffer from
hunger
– Prevalence of underweight in children under
five years of age
– Proportion of population below minimum level of
dietary energy consumption

The Nutrition Transition
An Emerging Global Epidemic of
Obesity
BMI > 30 kg/m2; Overweight BMI > 25 kg/m2

Trends in Prevalence of Underweight and
Obesity in the Poorest and Richest 25% of
Brazilian Women
MonteiroC, CondeW, PopkinB. AJPH 2004;94:43326101418

Prevalence of stunting in < 5
yr/old children

World poverty, 1981-2001
% of people living with <US$2 per
day

The Nutrition Transition
• Demographic trends
– Urbanization
– Increase in life expectancy
– Reduction in infant mortality
• Food availability and cost
– Changes in food type, availability and cost
– Changes in eating behaviors
• Lifestyle
– Reduction in energy demands at work
– Reduction in energy demands of daily survival activities
– Limited leisure physical activity
– Television

Age shifts in world population

Urban growth
Annual increase, 1990-2000

Food commodities –Global
trends

Trends in employment type in
South Asian transitional
countries

Disease burden in the
developing world

Causes of Malnutrition
• Malnutrition, is not a simple problem with a
single, simple solution
• Multiple and interrelated determinants are
involved in why malnutrition develops, and a
similarly intricate series of approaches,
multifaceted and multisectoral, are needed to
deal with it 527

Causes of Malnutrition…
• Causes could be categorized as:
– Immediate causes
– Underlying causes, and
– Basic causes
528

Malnutrition - Immediate causes
Immediate causes
• The interplay between the two most
significant immediate causes of malnutrition -
inadequate dietary intake and illness -
tends to create a vicious circle:
• A malnourished child, whose resistance to 530

Malnutrition - Immediate
causes…
• Children who enter the malnutrition-infection
cycle can quickly fall into a potentially fatal
spiral as one condition feeds off the other
• Malnutrition lowers the body‘s immune-
response mechanisms.
– This leads to longer, more severe and more 531

Inadequate dietary
intake/disease cycle
Disease:
- Incidence
- severity
- duration
Appetite loss
Nutrient loss
Malabsorption
Altered
metabolism
Inadequate
dietary intake
Weight loss
Growth faltering
Immunity
lowered
Mucosal damage
532

Malnutrition - Immediate
causes…
• Infections cause loss of appetite,
malabsorption and metabolic and behavioral
changes.
• These, in turn, increase the body‘s
requirements for nutrients, which further
affects young children‘s eating patterns and
how they are cared for 533

Malnutrition - Underlying causes
• Three clusters of underlying causes lead to
inadequate dietary intake and infectious
disease:
– inadequate access to food in a household;
– insufficient health services and an
unhealthful environment; and
– inadequate care for children and women
534

(HHFS)…
Household food security (HHFS)
– is defined as sustainable access to safe food
of sufficient quality and quantity - including
energy, protein and micronutrients - to ensure
adequate intake and a healthy life for all
members of the family
535

(HHFS)…
• In rural areas, HHFS may depend on access to land and
other agricultural resources to guarantee sufficient
domestic production
• In urban areas, where food is largely bought on the market,
foods must be available at accessible prices
• Other potential sources of food are by exchange, gifts from
friends or family and in extreme circumstances food aid
provided by humanitarian agencies 536

(HHFS)…
• HHFS depends on access to food -
financial, physical and social - as distinct
from its availability
537

(Services and sanitation)…
• Health services, safe water and sanitation
– access to curative and preventive health services
that are affordable and of good quality
– Families should have a health centre within a
reasonable distance, and the centre‘s staff
should be qualified and equipped to give the
advice and care needed
538

(caring)…
• Caring practices
– even when there is adequate food in the house
and a family lives in a safe and healthful
environment and has access to health services,
children can still become malnourished
– Inadequate care for children and women, the
third element of malnutrition‘s underlying causes,
has only recently been recognized and 539

(caring)…
• Care is manifested in the ways a child is fed,
nurtured, taught and guided
• Nutritionally, care encompasses all measures
and behaviors that translate available food
and health resources into good child growth
and development 540

(caring)…
• In communities where mothers are supported
and cared for, they are, in turn, better able to
care for young children
• Among the range of caring behaviors that
affects child nutrition and health, the following
are most critical: 541

(caring)…
• Feeding:
– The introduction of complementary foods is a
critical stage. A child will be put at increased risk
of malnutrition and illness if these foods are
introduced much before the age of six months, or
if the preparation and storage of food in the home
is not hygienic
– Good caring practices need to be grounded in 542

(caring)…
– Other behaviors that affect nutrition include
whether children are fed first or last among family
members, and whether boys are fed
preferentially over girls
• Protecting children’s health:
– Ensure that children receive essential health care
at the right time (e.g. immunizations, and early
treatment)
543

(caring)…
• Support and cognitive stimulation for
children:
– For optimal development, children require
emotional support and cognitive stimulation, and
parents and other caregivers have a crucial role
in recognizing and responding to the actions and
needs of infants
– Breastfeeding affords the best early occasion to
provide support and stimulation 544

(caring)…
– Verbal stimulation by caregivers is particularly
important for a child‘s linguistic development
– Ill or malnourished children who are in pain and
have lost their appetite need special attention to
encourage them to feed and take a renewed
interest in their surroundings during recovery
545

(caring)…
• Care and support for mothers:
– As long as the unequal division of labour and
resources in families and communities continues
to favour men, and as long as girls and women
face discrimination in education and employment,
the caring practices vital to the nutritional well-
being of children will suffer
– Adolescent pregnancy is a major risk factor for
both mother and infant, as the girl may not have546

Malnutrition - Basic causes
– It is often said that poverty at the family level is
the principal cause of child malnutrition
– Political, legal and cultural factors at the
national and regional levels may defeat the best
efforts of households to attain good nutrition for
all members
547

Malnutrition - Basic causes…
– These include:
• the degree to which the rights of women and girls are
protected by law and custom;
• the political and economic system that determines how
income and assets are distributed; and
• the ideologies and policies that govern the social
sectors
548

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