Behaviour Change

GESTATIONAL DIABETICS

OBJECTIVES

•Awareness generation

•Prevention of Diabetes

•Control of diabetes

•Change of food habit and treatment

WHI IS PRONE FOR GDM

•Over weight (above 60 Kg)

•Diabetes during previous pregnancy

•Family history of diabetes

•Elderly pregnancy

•Already delivered with very high or very low birth weight baby

•Premature or still birth

•Frequent abortions

•Delivered with physically challenged baby

SYMPTOMS

•Increased thrust, increased appetite,

CONSEQUENCES OF UNCONTROLLED GDM

•Abortion

•Premature delivery

•Big baby

•Asphyxia

•Still birth or infant death

•Congenital malformations

•Risk of diabetes for the child at the age of 30 increases

Risk of postnatal diabetes

WHEN TO TEST

•During AN period (for all mothers)

–16^th week

–24^th week

–32^nd week

•During PN period (only for GDM affected mother)

–Within a week after delivery

–After six months

–After one year

WHAT TEST

•Glucose Tolerance Test (GTT)

HOW TO DO THE TEST

•Pregnant mother should come to the PHC with empty stomach at 8 am

•By using semi auto analyzer or glucometer blood test to be done

•After blood test 75g glucose in 300ml water is administered

•The test repeated after two hours

JE Programme

EPIDEMIOLOGY OF JAPANESE ENCEPHALITIS IN INDIA
Japanese Encephalitis
Ø Japanese Encephalitis is an arthropod-borne viral disease transmitted by mosquitoes.
Ø Causes serious inflammation of the brain.
Ø May lead to permanent brain damage.
Ø Carries a high mortality rate.
Ø Human Encephalitis in JAPAN recognized as early as 1871.
Ø JE in epidemic form has been known since 1924.
Ø 4000 human deaths recorded in JAPAN.
Global scenario
Major public health problem in Asia.
Virus first isolated in Japan in 1935.
As per WHO estimates 50 thousand serious cases and 10 thousand deaths each year.
Disease is prevalent in Indian Sub-continent: Nepal, India Sri Lanka and some areas in Bangladesh.
Other SE Asian countries reporting cases include:
Ø Myanmar, Thailand, Cambodia, China,
Indonesia, Laos, Vietnam, Malaysia, Philippines, Taiwan,
Hong Kong and Korea
DISTRIBUTION OF JAPANESE ENCEPHALITIS
• Japanese encephalitis is endemic in India, China, Japan, and all of South East Asia.
• Japanese encephalitis is the leading cause of viral encephalitis in Asia, with 30,000–50,000 cases reported annually.

JAPANESE ENCEPHALITIS IN INDIA
« 1952 - First evidence of JE viral activity by
VRC (NIV) during sero-surveys for arbo-viruses.
« 1955 - First human case of JE.
« 1958 - First viral isolation from JE case.
« 1973 - First outbreak- Bankura and Burdwan in West Bengal.
« 1976 - Repeat outbreak in Burdwan.
« 1978
• Widespread occurrence of suspected JE cases.
• National level monitoring initiated by NMEP in 1978.
Initiation of immunization using inactivated mouse brain vaccine
JE affected areas
v Andhra Pradesh
v Assam
v Bihar
v Goa
v Haryana
v Karnataka
v Kerala
v Maharashtra
v Manipur
v Tamil Nadu
v Uttarakhand
v Uttar Pradesh
v West Bengal
v Nagaland

EPIDEMIOLOGY
Japanese encephalitis is a flavivirus that is transmitted by the mosquito Culex tritaeniorhynchus.
The mosquitoes that transmit the virus breed in rice fields, and standing water
Majority of infections occur in rural areas and occur during July and October coinciding with monsoon and postmonsoon period.
The virus can also infect other vertebrates like birds and pigs.
Japanese encephalitis is primarily a childhood disease because people develop immunity through exposure.
The majority of cases occur in people under the age of 15.
CLINICAL FEATURES
Incubation Period - 5 to 15 days
only 1 in 250 infections develop into encephalitis, rest asymptomatic
Fever with severe rigor, headache and malaise
Acute encephalitic stage include
– neck rigidity
– hemiparesis
– convulsions
– Coma
CFR: Around 20% (in India), higher in children
30% of the people that survive the infection develop paralysis, brain damage, or other serious permanent sequelae
JE vectors
Major JE vectors:
Cx. tritaeniorynchus
Cx. pseudovishnui
Cx. vishnui

Ecology of vectors
Prolific breeders in rice fields, irrigation channels, other small water collections with vegetation
Majority rest outdoors
Primarily zoophilic
High densities in monsoons & post monsoons

Clinical spectrum of JE infection
Ø For every symptomatic JE case, there are likely to be about 300 – 1000 people infected with JE virus but without any clinical manifestation
Ø Children between 1 to 15 years of age are mainly affected in endemic areas.
Ø But people of any age can be infected. Adult infection most often occurs in areas where the disease is newly introduced.
Prognosis
Depends on cause and severity of illness and patient’s age.
Mild cases recover in 2 to 4 weeks with supportive care.
Severe encephalitis can lead to numerous complications.
– Hearing and/or speech loss, blindness, permanent brain and nerve damage, behavioral changes, cognitive disabilities, lack of muscle control, seizures, memory loss.
Seasonality
Almost all the states exhibit uniform seasonality
Assam shows a different pattern
Sometimes two peaks recorded in some states like Tamil Nadu due to two monsoon peaks

STRATEGIESFOR PREVENTION AND CONTROL

Surveillance for cases of encephalitis
For surveillance purposes, JE is also commonly reported under the heading of
“acute encephalitis”.
In WHO’s guidelines for JE surveillance, syndromic surveillance for JE is recommended. This means all cases of acute encephalitis syndrome (AES) should be reported.
Laboratory confirmation of suspected cases is done where feasible.

INTENSIFIED PULSE POLIO IMMUNISATION
MICRO PLAN DECEMBER 2008 & FEBRUARY 2009
NAME OF THE HEALTH DISTRICT: CHEYYAR
1.No.Of PHC : 35

Number of Municipality : 3

No of HSCs : 157

2.POPULATION ITEM RURAL URBAN TOTAL

Enumerated Population 789627 126869 916496

Enumerated Children 74098 12514 86612

3.PLACES IDENTIFIED FOR IMMUNISATION POST PLACES
RURAL URBAN TOTAL
a.HSC's 34 3 37

b.PHC's 7 0 7

c.Govt.Hospital 0 3 3

d.Private Hospital 0 0 0

e.Schools 150 14 164

f.Nutrion Centers 419 9 428

g.Choutries etc. 0 0 0

h.Others-Temples 18 5 23

h.Others-Library 1 0 1

h.Others- P.U.Building 10 1 11

h.Others-Savadi 1 0 1

h.Others-Private House 10 0 10
h.Others - Shop,
Community Hall etc 1 0 1

h.Others - TV Room 2 0 2

Total 653 35 688

Bus Stand / Transit 2 3 5

Grand Total 655 38 693

Pulse Polio Immunisation

Pulse Polio Immunisation

CHEYYAR HEALTH DISTRICT

21 st December, 2008
01 st February, 2009
14th year of mass campaign

Day 1 - Booth and House to House
Day 2 & 3 - House to House activity
Day 4 - Day 7 - Revisit of X houses

Sl.No Details

1 Total Population 916496

2 No. of PHCs 35

3 No. of Municipalities 3

4 No. 0-5 Yrs children 86612

5 No. of Houses 197017

6 No. of Booths Planned 690

7 No. of Transit Booths 3

8 No. of Supervisors 89

9 No. of staff involved 2772

10 No. of vehicles used 38

11 Vaccine Required (in Doses) 122000

POLIO ERADICATION STRATEGIES

ROUTINE IMMUNIZATION
NIDs (PPIs)
Acute Flaccid Paralysis (AFP) SURVEILLANCE
MOPPING-UP

What is AFP surveillance?
•Detect any case of AFP <>

Standard Case Definition Acute Flaccid Paralysis
Any patient under 15 years of age with acute, flaccid paralysis; or any person in whom a clinician suspects polio.
Onset of paralysis during last six months to be included as a case of AFP.
Plan for covering special population
•Same populations are often missed by the routine as well as SIAs
–Religious minority groups
–Multi-storied building (flats)
– Fishermen colonies
–Pavement dwellers
–Slum dwellers
–People with working hours that do not coincide with team visits
–People living in peri-urban areas
•Identify all such populations and ensure they are included in micro plans for coverage during each round.
Migrant Population

•Construction sites

»Factories
»IT Parks
»Railway gauge conversion
»Road construction
»Bridge construction
»Housing
•Brick kiln, quarry, etc
•Nomads – Narikuravas,

Migratory populations - Actions

•Identification of clusters with migratory populations from Bihar/ UP
•Mapping such areas
•Focus during PPI campaigns
•Plan for special polio campaign during March, 2008
•Plan for routine immunization.

Measles
• Highly infectious

• Transmitted through respiratory droplets or airborne

• Fever, rash, cough, conjunctivitis and coryza

• CFR 0.1% - 10%

• Vitamin A deficiency increases mortality

Clinical features
• Incubation period from exposure to onset of fever is usually 10 days.
• Initial symptoms and signs are high fever, runny nose, coryza, cough, red eyes and Koplik spots (small white spots on the buccal mucosa).
• Characteristic erythematous (red) maculopapular (blotchy) rash appears on the 3rd to 7th day, starting behind the ears and on the hairline and then spreading to the rest of the body.

Case Definition of Suspected Measles
Any person in whom clinician suspects measles infection during last one month(OR)
Any person with fever and rash and cough, coryza (running nose) or conjunctivitis (red eyes) during last one month.

For epidemiological investigation, clinical measles would be a case within last 3 months

Measles death definition
“A death which occurs within one month [30 days] of onset of measles”
– The Global Epidemiology of Infectious Diseases, WHO-2004

Objectives of Measles Surveillance
• Detect and investigate suspected measles outbreaks
• Improve case management of measles cases
• Identify high-risk populations/areas for measles
• Strengthening measles immunization coverage in these areas
• Monitor progress in reduction in measles mortality and morbidity

Operational criteria for conducting extensive outbreak investigation
• > 5 suspect cases of measles in a block in a week(OR)

• > 1 death due to measles in a block in a week(OR)

• > 5 suspect cases in an area bordering several blocks


• Outbreak Flag:
– 5 or more suspected measles cases are reported from one block or contiguous blocks in a week, OR
– 1 or more suspected measles deaths are reported from one block in a week
• Collate information at District level from
– weekly reports,
– AFP Informer network
– Other sources like IDSP/ICMR Measles network etc.

Sample Collection and Transport Kit
• 5ml syringe and needle or Vacutainer tube with 22 gauge needle and adapter
• 5ml externally threaded screw cap vials
• Tourniquet, sterile swabs & band aid
• Gloves
• Uricol disposable bottles
• Specimen labels
• Zip lock plastic bags
• Autoclavable disposal bags
• Cold box with ice packs
• Measles lab request form

Blood sample collection
• Apply tourniquet 2 - 3’’ above elbow, swab the cubital fossa.
• Draw 3-5 ml of blood by venipuncture using syringe
• Discard Needle into disposable bags / needle destroyer. Be careful of needle stick injury
• Push the blood gently into sterile labeled tube. (do not push blood through the needle). Discard the barrel of syringe into auto clavable disposal bags
• Leave the tube at RT for 30mins for clot formation.
• Clotted Blood can be stored at 4-8deg C for up to 24 hours. Do not freeze whole blood
• Fill up lab request: Three dates are important: Dates of last measles vaccination, of rash onset, & collection of sample

Factors responsible for increased rate/severity of complications & deaths in measles
• Young age
• Malnutrition
• Vitamin A deficiency
• Overcrowding
• Immune deficiency (~HIV)

MEASLES REPORTING
• Gross under reporting
v Perception of disease
v Workers perception vs. immunization
v Outbreak response immunization

REPORTING GUIDELINES
Ø All Block PHC will be a reporting unit

Ø All the additional PHCs will send weekly report to the Block PHC every Monday (Form VPD-H002) (2 copies)
Ø All the Block PHCs will send consolidated weekly report VPD-H002 (2 copies) based on additional PHC reports including block PHC area to DDHS office by Tuesday noon
Ø Weekly Hospital report VPD-H002

Global Strategy for sustainable measles mortality reduction
Strong routine immunization of > 90%
Reaching Every District strategy.

2. Provide second opportunity for measles immunization
• One time only “catch-up” campaign (< 15)
• “Follow-up” campaigns every 3-4 years (< 5)
• Integration of campaigns with other priority health interventions
(Vit A, polio, TT, bed nets)
3. Surveillance

4. Improved case management Vitamin A - antibiotics