Chinmayee Potti

Community Medicine Notes

3rd Semester

Transcribed by: Pranav Mishra

Notes from 2011 || Transcribed in 2014
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Contents
Evolution of Health and Medicine ................................................................................................................ 3
Health ............................................................................................................................................................ 4
Determinants of Health ................................................................................................................................ 5
Health Indicators ........................................................................................................................................... 6
Disability........................................................................................................................................................ 8
Epidemiology................................................................................................................................................. 9
Disease ........................................................................................................................................................ 12
Control of Diseases ..................................................................................................................................... 13
Nutritional Problems in India ...................................................................................................................... 17
Nutrition...................................................................................................................................................... 20
Proteins ....................................................................................................................................................... 23
Carbohydrates............................................................................................................................................. 25
Fats .............................................................................................................................................................. 26
Vitamins ...................................................................................................................................................... 29
Iron .............................................................................................................................................................. 34
Iodine .......................................................................................................................................................... 37
Fluorine ....................................................................................................................................................... 39
Malnutrition ................................................................................................................................................ 40
Protein Energy Malnutrition (PEM) ............................................................................................................ 40
Food Borne Diseases ................................................................................................................................... 46
Food Fortification........................................................................................................................................ 49
Noise Pollution ............................................................................................................................................ 51
Radiation ..................................................................................................................................................... 53
Air Pollution ................................................................................................................................................ 55
Meteorological Environment ...................................................................................................................... 57
Water .......................................................................................................................................................... 59
Water Purification ....................................................................................................................................... 61
Waste Disposal ............................................................................................................................................ 65

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Evolution of Health and Medicine

History
 1848 - Public Health Act implemented (in the UK)
o Just by improving living conditions, TB incidence decreased
 Birth of Preventative Medicine (by improvement of living conditions)
o As infectious diseases decreased in number, non-communicable diseases increased in
number
 Risk factors for non-communicable diseases (ex diabetes)
o Obesity
o Sedentary lifestyle
o High cholesterol diet
 With increase in amount of non-communicable diseases, medical revolution took place
o X-rays, CT, MRI, etc
 However this revolution did not have any impact on incidence of non-communicable diseases as
the inventions were unavailable to the common man
 Thus, improvement in the delivery of medicine had to take place: "Healthcare Revolution"
 1978 - "Alma Declaration" taken by several countries: "De-Professionalization" of medicine where
nurses were also trained in every aspect and so doctors were not required for every case
 [MDG]: Millennium Development Goal → Set date 2015 to reduce
o Injurious disease
o Maternal health
o Child Health
 Cholera epidemic - 1854
 1928 - Penicillin invented

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Health
Definitions
Oxford: "Soundness of body or mind; that condition in which functions are duly and efficiently
discharged"

Webster: "Condition of being sound in body, mind or spirit, especially freedom from physical disease or
pain"

WHO: "Health is a state of complete physical, mental, and social well-being and not merely an absence
of disease or infirmity"

Operational definition, WHO: "Condition or quality of human organism expressing the adequate
functioning of the organism in the given condition genetic or environmental"

Dimensions of Health
 Physical
 Mental
 Social
 Spiritual
 Emotional
 Vocational

Other dimensions of health

 Philosophical
 Cultural
 Environmental
 Educational
 Curative
 Nutritional

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Determinants of Health
Health is multifactorial
Factors influencing health could be within the individual or externally in society

Individual Aspects
 Sociocultural
o Faulty practices
o Cultural taboos
 Aging of the population
o Increases non-communicable diseases
 Science and technology
 Education
o Especially female literacy

Families
 Equity and social justice
 Gender
 Information and communication

Societies
 Environmental (hygiene): Internal and external
 Socioeconomic
o DM and Coronary artery disease
o TB in poor populations
o Stress involved
o Obesity

Communities
 Human rights
 Biological Genes
 Behavioral (lifestyle factors)
o High risk behaviors: smoking, alcohol, risky sex

Determinants of Health
Medical Determinants
Agriculture, IT, Science, Technology
 Awareness
 Communication
 Improving diagnostic modality, etc

Non-medical determinants

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Health Indicators
Need for Health Indicators
1. To measure the health status of a community
2. Compare health statuses of 2 regions
3. For assessment of health care needs
4. Allocation of resources
5. To monitor and evaluate health services

Characteristics of Health Indicators

1. Valid
2. Reliable
3. Sensitive
4. Specific
5. Feasible
6. Relevant

Includes as measure of
 Mortality: deaths
 Morbidity: diseases
 Disability

Mortality Indicators
Crude Death Rate

Specific mortality rates

Infant Mortality Rate:

Infant = less than 1 year of age

Maternal Mortality Rate

Death of the mother = during pregnancy or within 42 days of the termination of pregnancy
 Ignores accidental or incidental deaths

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Disease Specific Mortality Rate

Proportionate Mortality Ratio

Morbidity Indicators
 Incidence
 Prevalence
 Attendance at OPDs
 In-Patient days

Incidence
Number of new cases occurring in a defined population during a specified period of time

Expression form: 15 people per 1000 population per year

Prevalence
Number of people with a disease or an attribute at a specified point of time

--> Includes new and old cases

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Disability
Disability Indicators
Sullivan's Index:
 Life expectancy - Duration of disability

Health adjusted life expectancy

 No of years in full health that a new born can expect to live based on current rates of ill health
and mortality

Disability Adjusted Life Years (DALY)

 Years of life lost to premature death
 1 DALY = 1 lost year of healthy life

Nutritional Health Status Indicators

Examples
 Prevalence of malnutrition among under-fives
 Prevalence of low birth weight (< 2.5 kg)

Health Care Delivery Indicators

 Human resources in health
o Doctor: Population Ratio
o Doctor: Nurse Ratio
o Population per health centers
 Utilization rates
o Proportion of infants fully immunized
o Proportion of pregnant women receiving antenatal check up's
Socioeconomic Indicators
 Literacy
 Income
 Access to safe water
 Sanitary measures

Health Development Indicators

Quality of Life
 Physical Quality of Life Index (PQLI): Infant Mortality Rate (IMR), Life expectancy at age 1, and
literacy
 Human Development Index: Life expectancy at birth, knowledge and income
 Gender Development Index

Environmental Indicators
 Health policy indicators
 HPA Indicators
 MDG Indicators

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Epidemiology
Definition
"Epi" = above, among
"Demos" = people
"Logos" = study

Epidemiology is concerned with the

 Distribution and determinants of health related events in population
 Application of this study to the control of health problems

Natural History of Disease

Period of Pre-pathogenesis: before man is involved
 A state of equilibrium between agent, host, and environment

Period of Pathogenesis: man is involved

 Disruption of the equilibrium can lead to occurrence of disease

Pre-Pathogenesis Phase: Susceptibility Phase

Host (Human) Factors

 Age
 Sex
 Built

Environmental Factors
 Poor sanitation
 Safe drinking water
 Low socio-economic status

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Agent: Causative organism

 Agent for infectious disease
 Risk factors for disease

Period of Pathogenesis

Agent Factors
Agent: must be present for an infection to occur

Characteristics of infectious disease agents

1. Infectivity: able to produce illness
2. Pathogenicity: able to produce signs and symptoms
3. Virulence: able to produce severe illness

Types of Agents
 Biological - microorganisms
 Nutrient - deficiencies and toxicity
 Physical - radiation
 Chemical - drugs, gases (poisons)
 Mechanical - cause of injury
 Social - alcohol, smoking, etc

Host Factors
 Demographic
 Biological
 Socioeconomic
 Lifestyle factors

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Pre- Pathogenesis
pathogenesis Phase
Phase

Susceptibility Asymptomatic Clinical Stage Disability Stage Death

Stage Stage Stage

Primary Secondary Tertiary Palliative

Prevention Prevention Prevention Care

Level 1: Health Level 2: Early diagnosis Level 1: Disability Level 2:

Promotion Specific and treatment limitation Rehabilitation
Protection

Smoking, Vaccination, Screening Chronic disease Physical,

drinking using surveillance and vocational,
cessation; diet, protective management psychological
exercise devices rehabilitation

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Disease
A condition in which
 Body health is impaired
 A departure from a state of health
 An alteration of the human body
 Interrupting performance of vital function
Spectrum
 Subclinical infection
 Mild disease
 Moderate disease
 Severe disease
 Fatal disease
 Death

Iceberg Phenomenon
 Apparent cases
 Water line
 In-apparent cases: not noticed/ undetected

Challenge
 Hidden part of iceberg - undiagnosed reservoir of infection or disease in the community
 Detection and control of this part of the iceberg
o Challenge to modern techniques in preventive medicine

Risk Factors
At risk groups
 Biological situation - genetically susceptible, age, gender, obesity
 Physical situation: environment in which they live
 Socioeconomic situation: occupation, beliefs and customs, lack of physical activity/ sedentary
lifestyle

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Control of Diseases
Disease Control
In disease control the agent is permitted to persist in the community at a level where it ceases to be a
public health problem according to tolerance level of the population

Aimed at reduce the

 Incidence of disease
 Duration of disease and risk of transmission
 Effects of infection
 Financial burden to the community

Disease Elimination
Precursor of eradication

Interruption of transmission of disease from large geographical areas

E.g.: polio, measles

Disease Eradication
Termination of all modes of transmission of infection by termination of infectious agents

Cessation of infection and disease from the whole world

E.g.: small pox

Challenges in Eradication
 Hidden foci of infection
 Unrecognized modes of transmission
 Resistance of vector to control measures

E.g.: failed control programs to eradicate malaria, leprosy, plague, etc

Prevention
Concept of Prevention
Depends on:
 Knowledge of causation
 Dynamics of transmission
 Identification of risk factors and risk groups
 Availability of prophylactic or early detection and treatment resources
 Organization for applying these measures
 Continuous evaluation and development of procedures applied

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Levels of Prevention
 Primordial
 Primary
 Secondary
 Tertiary

Primordial Prevention
Prevention of the emergence or development of risk factors in countries or population groups in which
they have not yet appeared
 Useful in prevention of chronic illnesses
 Main interventions are through individuals and mass education: lifestyle modification

Primary Prevention
Action taken prior to the onset of disease, which removes the possibility that disease will ever occur
 Signifies intervention in pre-pathogenesis phase of disease
 In chronic diseases involves the modification or elimination of risk factors
 Interventions are health promotion and specific protection

Ex: non-smoking promotion

Approaches for Primary Prevention

Population Strategy: directed towards socioeconomic, behavioral, and lifestyle changes
 Preventive measure widely applied to an entire population
 Must be relatively inexpensive and non-invasive

High-risk strategy: Prevention care to individuals at special risk

Secondary Prevention
Action which halts the progress of a disease at its incipient stage and prevents complications
 Early pathogenesis phase
 Expensive and less effective than primary prevention
 The Specific interventions are early diagnosis and adequate treatment

E.g.: early diagnosis of cervical cancer using pap smears

Tertiary Prevention
All measures available to reduce or limit impairments and disabilities, minimize the suffering caused by
existing departures from good health and promotion of the patient's adjustment to non-remedial
conditions
 Significant intervention in late pathogenesis
 Intervention includes disability limitation and rehabilitation

E.g.: use of splints and remedial exercises to prevent contractures and deformities in rheumatoid
arthritis

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Modes of Intervention
Primary
1. Health promotion
2. Specific promotion

Secondary
1. Early Diagnosis
2. Appropriate treatment

Tertiary
1. Disability limitation
2. Rehabilitation

Health Promotion
Process of enabling people to increase control over and improve health
 Health education
 Environmental modification: safe water, housing
 Nutritional intervention: supplementary nutrition, fortification
 Lifestyle and behavioral changes - diet and physical activity

Specific Protection
 Immunization: polio
 Chemoprophylaxis: malaria
 Use of specific nutrients
 Protection against accidents
 Protection from occupational hazards: lead poisoning
 Control of specific hazards in environment: air pollution

Early Diagnosis and Treatment

 Screening: Breast CA, oral CA
 Treatment: TB, leprosy

Disability limitation
 Prevents the transition of the disease process from impairment to handicap

Impairment
Any loss or abnormality of psychological, physiological, or anatomical structure or function

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Disability
Any restriction or lack of ability to perform an activity in the manner or within range considered normal
for a human being

Handicap
A disadvantage for a given individual resulting from an impairment or a disability that limits or prevents
the fulfillment of a role that is normal for that individual

Rehabilitation
Combined and coordinated use of medical, social, educational, and vocational measures for training and
re-training the individuals to the highest possible level of functional ability

Types
 Medical restoration of function
 Vocational restoration of capacity to earn a livelihood
 Social restoration of family and social relationships
 Psychological rehabilitation of personal dignity and confidence

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Nutritional Problems in India

Factors which Hamper Improvement of Nutritional Status
 Poverty
 Lack of awareness
 Rapid population growth
 Faulty feeding practices
 Infections

Common Nutritional Problems in India

 Protein energy malnutrition (PEM)
 Vit A deficiency (VAD)
 Anemia
 Iodine deficiency disorder (IDD)
 Low birth weight (LBW)

 Over nutrition

Protein Energy Malnutrition (PEM)

 Major problem in India, exists in all of the states
 Affects 1-2% of preschool age children in India
 Majority of cases are mild/moderate and may go unrecognized
 In 1970s, PEM thought to be due to protein deficiency
 Over the years, concept of "protein gap" has been replaced by concept of "food gap"
 PEM is due to infections and inadequate food intake

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Vitamin A Deficiency (VAD)

 Xerophthalmia refers to ocular manifestations of Vit A deficiency
 Most common in children aged 1-3 years
 Often associated with PEM
 Infection such as diarrhea, measles often precipitate Xerophthalmia

Anemia
 Condition in which Hb content in blood is less than normal
 Most frequent cause of nutritional anemia is Iron deficiency
 Highest prevalence in developing countries
 Common among women of child bearing age, young children, and during pregnancy and lactation
Factors leading to anemia
 Iron deficiency may arise from
o Inadequate intake
o Poor bioavailability of dietary iron
o Due to excess loss
o Malaria
o Hookworm infestation

Iodine Deficiency Disorders

 Iodine deficiency was equated with goiter earlier
 Leads to spectrum of disorders from intrauterine period onwards
 Social impact arises from effects on CNS

Low Birth Weight (LBW)

Less than 2.5 kg
 Public health problem in many developing countries

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 About 28% babies born in India are LBW

 Causes
o Maternal malnutrition
o Anemia
o High parity

Over-nutrition
 Consumption of too many calories relative to activity level → more calories than needed
 Over time it leads to obesity which can result in
o DM
o HTN
o Heart disease

Programs to control nutritional problems in India

 Integrated child development services (ICOS)
 Mid-day Meal Program
 National Vit A prophylaxis Program
 National Nutritional Anemia Prophylaxis Program
 National Iodine Deficiency Disorders Control Program

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Nutrition
Nutrition - science of food and its relationship to health
Nutrient - specific dietary constituents
 Macronutrients
o Proximate principles: form major bulk of food
 Proteins: 7-15% of total energy intake
 Fats: 10-30%
 Carbs 65-80%
 Micronutrients

Nutrition
Knowledge regarding
 Origin
 Chemical composition
 Functions of food items

Energy requirements
 For basal metabolism: 1 kcal/hr for every kg of body weight of an adult
 For daily activity/occupational work: varies based on type of activities

Balanced Diet
Defined as one which contains a variety of foods in such quantities and proportions that the needed
energy, AA, vitamins, minerals, fats, carbs is adequately met for maintaining health and also makes a
small provision for a period of leanness (?)

Principles
 10-15% of daily energy intake from protein
 15-30% from fat
 Carb rich in fibers should constitute remaining food

Food Pyramid
 Dietary goals
 Energy requirements
 Factors affecting energy requirements
 Reference man and woman
 Vulnerable groups

Assessment of Nutritional Status

Methods
 Anthropometry
 Biochem evaluation
 Clinical eval

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 Diet intake assessment

 Ecological studies
 Functional assessment
 Vital and health statistics

Anthropometry
 Height, weight, BMI, mid-arm circumference
 Recorded over a period of time to reflect patterns of growth and development

Laboratory and Biochemical Assessment

 Hb
 Stools (parasite invasion) and urine
 Nutrient concentration (serum iron, retinol, etc)
 Abnormal amounts of metabolites in urine (urinary iodine)
 Measurement of enzymes

Clinical Exam
 Signs known to be
o Of value
o that need further investment
o Not related to nutrition
 Drawbacks:
o quantification of malnutrition difficult,
o lack of specificity,
o subjective nature of features,
o lack of signs in many deficiencies

Assessment of Dietary Intake

Dietary surveys by household inquires
 Weight of raw foods - survey for 1 dietary cycle of 7 days duration
 Weight of cooked foods
 Oral questionnaire method: 24-48 hour dietary recall

Functional Indicators
 RBC fragility
 Prothrombin time
 Sperm count
 Nerve conduction

Vital statistics
 Morbidity
 Mortality

Ecological Factors
 Food balance sheet

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 Socioeconomic factors
 Health and education system
 Conditioning influence (infections)

Nutritional Status Indicators

 Maternal nutrition
 Infant and preschool child nutrition
 School child nutrition

Nutritional Surveillance
 Keeping watch over nutrition in order to make deicsions that will lead to improvement in nutirtion
in population (difficult)
 Growth monitoring (for children < 5) → individual over period of 7 years
 For large population at 1 point in time
Look up comparison tables

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Proteins
Sources
Animal Sources
Milk, egg, cheese, fish, meat

Rich in essential amino acids (AA)

Vegetable Sources
Pulses, cereals, beans, nuts, oil seeds

Poor in essential AA

Functions
1. Body building
2. Repair and maintenance of body tissues
3. Synthesis of enzymes, antibodies, plasma proteins, Hb, hormones, coagulation factors
4. Energy (4 kcal/g)

Supplementary action of proteins

Limiting Aas
 Cereal proteins deficient in lysine and tyrosine
 Pulse proteins deficient in methionine

When 2 or more vegetarian foods are consumed together, proteins supplement each other

Provide protein comparible to animal proteins (ex: rice and dal)

Quality of Protein:
 Assessed by comparison to reference protein (usually egg albumin - biologically complete)
 Method of assessment
o AA score
o Net protein utilization

Amino Acid Score

Examples:
 Starch: 50-60
 Animal foods: 70-80

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Net Protein Utilization (NPU)

 Product of digestiblity coefficient and biological value divided by 100
 Proportion of ingested protein that is retained in the body for growth and maintenance

1g protein = 6.25g of Nitrogen

 Protein requiremetn varies with NPU of dietary protein

 If NPU is low, protein requiremetn is high
 NPU of protein of Indian diet: 50-80

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Carbohydrates
Sources
 Starch: cereals, roots, tubes
 Sugars: mono and disaccharides
 Cellulose: indigestible fibers

Uses
 Main source of energy: 4 kcal/g, contributes to 50-70% of total energy intake
 Essential for oxidation of fats
 Synthesis of non-essential AA

Dietary Fiber
 Mainly non-starch polysaccharides
 Found in vegetables, fruits, and grains
 2 kcal/g
 Broadly divided into
o Insoluble fibers - cellulose
o Soluble fibers - non cellulose - pectin, inulin, plant gums
 RDA: 40g/day
o Indian diet: 50-60g: whole grain, cereals, pulses, vegetables are consumed daily

Function
 Absorbs water, increases bulk of stool, decreases constipation
 Decreases putrefaction and formation of gases and toxic substances
 No fecal mutagen synth and decreased chances of colon/stomach cancer
 Associated with reduced incidence of coronary artery disease (reduction in cholesterol)
 Gum and pectins: decrease post-prandial glucose levels

Refined Carbohydrates
 Foods which have been processed (milling): strips the bran and grain from the whole grain
 Concentrates the carbohydrate so that the body processes it quickly → increase in blood glucose
 Gives food a finer texture and prolongs shelf life
 Removes important nutrients: Vit B, fiber, bran
Eg: white rice, white bread, pastries, biscuits, dessert, toffee/sweets

Glycemic Index
 A way of ranking carbohydrate foods based on how quickly they raise blood sugar levels
 Factors affecting
o Texture
o Type of cooking
o Processing used
o Amount of sugar present
 Foods with low Glycemic Index: oats, pulses, ground nuts
 Foods with high glycemic index: white rice, bread, potatoes

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Fats
Macronutrients that provide concentrated source of energy
 9kcal / gram of fat
 Found in blood and body cells

Types
 Simple lipids: triglycerides
 Compound lipids: phospholipids
 Derived lipids: cholesterol

Fatty Acids
Fats → Hydrolysis → Fatty acids + glycerol

Classification
Unsaturated
 Monounsaturated - oleic acid; olive oil, peanut butter, almonds, nuts
 Polyunsaturated -linoleic acids; safflower oil, sunflower oil, walnuts
 Oils at room temp
 Lower total cholesterol → Heart healthy

Saturated
 Animal sources - Stearic, Palmitic
 Increase blood cholesterol → increased risk of heart disease and stroke
 Cheese, whole milk, dark chocolate, butter, ice cream

Essential Fatty Acids

 Cannot be synthesized by humans → Derived only by food
o Ex: omega-6-FA, omega-3-FA
 Dietary sources of EFA:
o Dark green veg
o Veg oils, fish oil
o Meat
o Egg
 Helps lower LDL cholesterol → decreases risk of heart disease

Sources of Fats
 Animal fats: milk, butter, eggs, cheese, meat
o Saturated fats except fish oil
 Veg fats: groundnut, coconut, mustard
o Unsaturated fats except coconut and palm oils
 Other sources: invisible fats in cereals, pulses, nuts

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Visible and Invisible Fats

Visible Fats
Separated from their natural source
 Ghee from milk
 Cooking oil from oil bearing nuts

Invisible Fats
Not visible to naked eye, so difficult to estimate
 Present in almost every food
 Cereals, pulses, milk, etc

Hydrogenation
Insert hydrogenation picture

Refined Oils
 Done by treatment with steam, alkali
 Refining and deodorization of raw oils is done to remove from FA and rancid materials
 Doesn’t change unsaturated FA content
 Improves quality and taste of oils
 Costly process

Trans Fas
 PUFA → partial hydrogenation → Trans FA
 Unsaturated FA → Saturated FA
 Increases shelf life
 Used to fry food over and over again with going rancid
 Atherogenic and increased risk of CHD
 Decreases HDL cholesterol, increases LDL

Ex: Margarine, deep fried foods, French fries, most bakery goods

Functions of Fats
 Supply energy: 9kcal/g
 Improves palatability of food
 Slows digestion - resulting in satiety
 Vehicle for fat soluble vitamins
 Supports viscera - heart, kidneys, intestine
 Fat beneath skin - insulation against cold
 55% of energy from breast milk comes from fat
 EFA: needed from growth of body, decreased platelet adhesiveness, decreased serum
cholesterol and LDL
 Cholesterol: precursors for synthesis of steroid hormones and bile acids
 PUFA - precursors for prostaglandins → vascular homeostasis, GI motility, lung and renal
physiology

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How much do we need:

 Adults: 10-30% of calories
 50% intake - vegetable oils rich in EFA
< 10% saturated fats
 < 1% trans fats

Dietary Fat Requirement of Indians

 Adults: 20-40 g/day
 Infants: 25 g/day
 Young children: 25 g/day
 Adolescents: 35-45 g/day
 Pregnant/Lactating: 30 g/day

Fats and Disease

 Obesity
 Phrynoderma/toad skin - deficiency of EFA
o Deficiencies of vitamins A and E, B complex vitamins, and essential fatty acids have all
been implicated in the etiology of follicular hyperkeratosis
 Cancer: colon and breast

Choice of Cooking Oils

 Use of combination of oils
 PUFA rich sunflower oil + MOFA rich in groundnut oil
o Ω3 PUFA in mustard oil
 Avoid use of partially hydrogenated vegetable oils (PHVO)
o Replacement of PHVO: oils with high thermal stability like palm oil and rice bran oil

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Vitamins
Vitamins are organic substances that are essential for enzyme function in human metabolism

Essential nutrients, micronutrients

Thiamine was discovered in 1912 - thought to be "vital amine" → term "vitamin" coined

Categories
Fat soluble Water soluble

Dissolve in Fat Dissolve in water

Can be stored Carried in blood stream, not stored

A, D, E, K C and B complex

Vitamin A
Rich Dietary Sources
Animal Plant

(Preformed) Pro-vitamin: Carotenoids

 Cod liver oil  Sweet potato

 Liver and kidney  Carrots
 Egg  Spinach
 Milk/cheese/butter  Apricot
 Fish and meat  Papaya, mango

Functions
 Vision: integrity of eye and formation of rhodopsin necessary for dark adaptation
 Immunity: Important for activation of T lymphocytes and maturation of WBC
 Maintaining integrity and normal functioning of glandular and epithelial tissue lining the skin
and internal organs
 Growth and development
 Anti-infective

Storage and Transport

 Liver stores Vit A as retinol palmitate, enough to last 6-9 months
 In severe protein deficiency, decreased production of retinol binding protein prevents
mobilization of liver retinol reserves

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Recommended Allowances
Life Stage RDA Retinol (mcg/day)

Infants 350

Children 400-600

Adolescents 600

Adults 600

Pregnant 800

Lactating 950

Risk Factors for Vitamin A Deficiency (VAD)

 Age: children 6 months to 5 years; older adults
 Diet: inadequate in quantity or quality
 Disease: infectious diseases, diarrhea, fever, measles, alcoholism, liver disease
 Cultural: use of veg or mangos is taboo, especially during feeding of infants and pregnant
women

Clinical Manifestations of VAD

Early
 Night blindness
 Xerosis (dry conjunctiva)
 Bitot's spots (white patches on conjunctiva)
 Dry, scaly skin
 Poor wound healing

Advanced
 Keratomalacia (ulceration and necrosis of cornea)
 Endophthalmitis - inflammation of inner coats of eye
 Blindness
 Hyper-keratinization of skin
 Loss of taste
 Growth retardation

Xerophthalmia (Dry Eye)

All ocular manifestations ranging from
 Night blindness - XN
 Conjunctival xerosis - X1A
 Bitot's spots - X1B
 Corneal Xerosis - X2
 Corneal ulcerations - X3A
 Keratomalacia - X3B

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 Fundal changes -X4

 Corneal scarring - X5

WHO criteria for public significance of VAD

Condition Prevalence (%) in children (6mo-6yrs)

Bitot's Spots > 0.5

Night Blindness > 1.0

Corneal xerosis > 0.01

Corneal ulcer > 0.05

Serum retinol < 10 mcg/L >5

Treatment
 Massive dose of 200,000 IU Retinol Palmitate orally on successive days
 Early treatment can reverse early stages of xerophthalmia

Prevention
Short term action (NIN strategy)
 Administration of single massive dose of oily preparation of Vit A
o 100,000 IU orally to children (6 mo-1 year)
o 200,000 IU orally to preschool children in community every 6 months (Ages 1-6 years);
 Medium term action
o Fortification of foods with Vit A: ex. Dalda (hydrogenated vegetable oil)
 Long term action
o Improvement of diet to ensure regular and adequate intake of Vit A
o Promotion of breast feeding
o Decreased frequency severity of contribution factors like PEM, measles, etc
o Improvement of environmental sanitation
o Immunization of infants
o Community participation

Vit A Prophylaxis Program

 Ministry of Health and Family Welfare launched program in 1970
 Administration of single massive dose of oily prep (listed above)
 First dose with measles vaccine (9 mo.)
 Second dose with 1st booster of DPT and OPV (1.5 yrs)
 Additional dose for children with xerophthalmia, measles, PEM

Toxic Effects of Vit A

 Pseudotumor cerebri
 Hypercarotenemia

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Vitamin D (sunshine vitamin)

Function
 Promotes absorption of calcium and phosphate
 Deposits them in bones and teeth

RDA
Adults: outdoor physical activities
Children 1-2 years: 10 mcg/ day

Sources
 Sunlight
 Milk
 Animal fats
 Fish oils

Vitamin D Deficiency (VDD)

 Rickets in small children
 Osteomalacia in adults

Vitamin C (Ascorbic Acid)

Function
 Helps produce collagen
 Maintains integrity of capillary walls

Sources
 Citrus fruits (highest = gooseberry)
 Other vegetables

RDA
Adults: 50-60 mg/day

Vitamin C Deficiency
Scurvy
 Poor wound healing
 Bleeding gums
 Petechiae/ purpura
 Hemarthrosis - bleeding into joint spaces

Vitamin B2 (Thiamine)
Function
 Helps produce energy from carbohydrates
 Precursor of TPP
 Involved in peripheral nerve conduction

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RDA
 1-1.7 mg/day

Sources
Whole grain

Deficiency manifestations
 Wet beriberi - CVS (Edema present)
 Dry beriberi - Nervous system (edema absent)
 Wernicke's encephalopathy - polyneuritis, ataxia
 Seen in alcoholics

Vitamin B3 (Niacin)
Functions
 Helps body use sugars, Fas
 Helps enzymes function normally

RDA
 Adults: 12-20 mg/day
 Sources: poultry, fish, beef, peanut

Vit B3 Deficiency - Pellagra

 Symmetry in sun-exposed area
 Lesions are dark, dry scaly
 Diarrhea: atrophy of intestinal villi can occur → malabsorption
 Dementia: irritability, insomnia, memory loss, psychosis

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Minerals

Iron
3-4 g in adult body
60-70% as circulating iron (hemoglobin)

Functions
 Formation of HB
 Carrier of oxygen from lung to tissues
 Muscle activity (myoglobin)
 Immune system
 Component of enzyme systems

Dietary Iron
 Heme iron: animal food like meats, fish, poultry
o Better absorption
o Readily available
 Non-heme iron: plant: cereals, veg, legumes
o Poor bioavailability due to phytate, oxalates
o Milk and tea do not contain iron

RDA
Age Group mg/day

Infants 46 mcg/kg

1-6 years 9-13

Adolescents 26-32

Adult Males 17

Adult Females 21

Pregnant 35

Dietary Absorption
 Site: duodenum and upper jejunum in ferrous state
 Dependent on Fe status of the body, Fe needs, disorders of GIT, type of diet
 Part of absorbed Fe - stored in RE system as ferritin
 Absorption from habitual Indian diets < 5%

Iron Losses
 Adults: 1-2 mg/day

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 Mainly through hemorrhage

o Physiological: menstruation
o Pathological: hook worms
 Basal losses - excretion through urine, sweat

Iron Deficiency Anemia (IDA)

Affects 66% of pregnant women and 50% of women in reproductive age group in developing countries
60-70% of women and young kids

Definition (WHO)
Reduction of Hb concentration below reference values

Age group Hb g/dL (venous blood)

Adult Male 13

Adult Female 12

Pregnant 11

6-14 yrs 12

6m-6yrs 11

Causes of IDA
 Inadequate iron intake
 Poor bioavailability of dietary iron
 Excessive loss
 Increased iron demand

Clinical Features
Symptoms
 Fatigability, irritability
 Dizziness
 Poor work performance
 Pica: appetite for things that have no nutritional value: dirt, clay, metal, chalk

Signs
 Dry, pale skin and mucosa
 Glossitis, stomatitis, angular cheilosis
 Spoon shaped nails (koilonychia)

Lab Findings
 Microscopic hypochromic anemia
 Decreased Hb
 Decreased MCV, MCH, MCHC

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 Decreased serum ferritin - most sensitive test

 Decreased transferrin, serum Fe
 Increased TIBC

Consequences of IDA
Nutritional anemia
 Increased material and fetal mortality
 Increased risk of premature delivery and low birth weight
 Learning disabilities and delayed psychomotor development
 Decreased work capacity
 Impaired immunity (high risk of infection)

Management of IDA
Correction of Fe deficiency
 Orally
 Intradermally
 IV
Treatment of underlying disease

Oral Iron Therapy

 Deworm the patient - albendazole (400mg)
 Optimal daily dose: 200 mg of elemental Fe
 Ferrous gluconate/fumarate/sulphate
 Necessary to continue treatment for 3-6 months after anemia is corrected
 Side effects: heartburn, nausea, diarrhea

Parenteral Iron Therapy

Is indicated when patient
 Demonstrates intolerance to oral Fe
 Loses Fe (blood) at a rate too rapid for oral intake
 Disorder of GIT

Preparation of Fe-dextran complex (50 mg/mL): IM/IV route → painful

Prevention of IDA
 Short term approach: Fe supplementation
 Long term approach: food fortification
o Addition of ferric ortho phosphate or FeSO4 with sodium bisulfate to common salt
o Consumption of iron fortified salt over 12-18 months

National Nutritional Anemia Prophylaxis Program

 By Ministry of Health and Family Welfare
 Beneficiaries: pregnant, lactating, and children < 12 yrs
 Objective: prevent mild and moderate cases of anemia
 Hb: 10-12 g/dL - daily supplementation
 Hb < 10 g/dL - referred to PHC

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 Through MCH centers, PHC, ICD projects

Supplementation pattern
Beneficiaries Elemental Fe Folic Acid Minimum Duration

Mother 100 mg 0.5 mg 100 days

6-60 mo. 20 mg 0.1 mg 100 days

6-10 yrs 30 mg 0.25 mg 100 days

Adolescents 100 mg 0.5 mg 100 days

Iodine
 Essential micronutrient
 Required for synthesis of thyroid hormones and normal growth and development
 Recommended daily intake:
o 150 mcg
o Preg: 250 mcg
 Lifetime required for 70 years is 5 g - one teaspoonful
o Total quantity is present in the body

Sources of Iodine
Food is the main source of iodine (90%)
 Meat, fish, dairy products
o High amounts in sea foods
 Vegetables, cereals
 10% from drinking water
 Iodine content of soil determines presence in water and locally grown foods

Spectrum of Iodine Deficiency Disorder (IDD)

1. Goiter, hypothyroidism
2. Cretinism
3. Spontaneous abortions, still births, birth defects
4. Defects of speech and hearing, squint, psychomotor defects
5. Retarded physical development, impaired mental function (13 IQ points lowered), poor scholastic
performance

Goitrogens
Chemical substances leading to development of goiter
 Interfere with iodine utilization by the thyroid
 Cyanoglycosides and thiocyanates in brassica group of vegetables

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o Cabbage
o Cauliflower

Problem Statement
 Total goiter prevalence in general population: 15.8% (WHO 2005)
 Prevalence of iodine deficiency in general population (39.8%) in SE Asia
 71 million people affected by goiter and other Iodine deficiency in India
 IDD was thought to be a problem in sub-Himalayan region

Progression of IDD
Historic National Goiter Control Program
Iodine deficiency = goiter = visible swelling
 No pain, cosmetic problem

Cretinism: a rare event = low priority

Current View (1984)

Deficiency leads to brain damage and learning disabilities
 Increased number of deaths
 Decreased child development and survival
 Human resource development = highest priority

Epidemiological Assessment of IDD

 Prevalence of Goiter
 Prevalence of cretinism
 Urinary and excretion for surveillance
 Estimation of T4 and TSH
 Prevalence of neonatal hypothy - sensitive indicator of environmental iodine deficiency
 Setting up of labs for Iodine monitoring - water soil, food, iodized salt, and estimation of
urinary/excretion
 Manpower in training and legal enforcement
 Mass communication for public education
 Changing food habits - very limited approach, food reflects…

Goiter Assessment (WHO)

Class Description

0 No palpable or visible goiter

I Detectable goiter only by palpation but not visible when the neck is in the neutral position,
moves with deglutition

II Visible goiter when head is in neutral position

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National IDD Control Program

 Launched in 1992
 Objective: reduction of prevalence of IDD in country to < 10% by 2012
 Components
o Surveys to assess magnitude of problem
o Production and supply of iodized salt
o Health education and publicity
o Laboratory monitoring
o Re-survey to assess impact of program

Vehicle for Iodine: Salt

 Iodination of salt is a simple process, convenient and effective for mass prophylaxis
 Cost of salt iodization: Rs. 0.10/person/year
 Iodization with KI
 Level of iodization fixed by Prevention of Food Adulteration (PFA)
o Not < 30 ppm at production level
o Not < 15 ppm at consumer level

Hazards of Iodization
 A person has to consume at least 10-50x normal daily dosage
 Iodine to trigger hyperthyroidism
 Risk of iodide goiter is less
 Mild increase in thyrotoxicosis and Hashimoto's thyroiditis

Iodized Oil
 Poppy seed oil in IM injection
 1 mL provides protection for 4 years
 Can be applied rapidly in places where iodized salt is in short supply
 More expensive, logistical problems
 Oral administration of iodized oil or sodium iodate tabs - simpler but more expensive

Fluorine
 Required for normal mineralization
 Bones and formation of dental enamel
 Double edged sword
 Deficiency - dental caries (cavities)
 Excess - dental fluorosis and skeletal fluorosis
 RDA = 4mg /day for adults

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Malnutrition
Complications
 Undernutrition
 Over nutrition
 Imbalance
 Specific micronutrient deficiency

Protein Energy Malnutrition (PEM)

 More common during infancy
 One of the main causes of childhood morbidity, mortality and impaired growth and
development
 Kwashiorkor and marasmus - 2 clinical forms of PEM
o Marasmus: more Common than kwashiorkor
o More commonly seen marasmic kwashiorkor

Malnutrition Infection Cycle

Causes of PEM
 Inadequate food intake (quantity and quality)
 Infections

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 Other factors
o Poor environmental conditions
o Large family size
o Poor maternal health
o Premature termination of breast feeding
o Cultural factors

Kwashiorkor
A type of severe PEM
 Characterized primarily by protein deficiency
 Appears about 12 months, when breast feeding is discontinued
 But can develop at any time during a child's formative years

Symptoms
 Edema in face, arms and legs
 Liver enlargement and ascites
 Dry peeling of skin (flaky point dermatosis)
 Hair discoloration (sparse, easily pulled out, positive Flag sign)
 Poor appetite
 Mental retardation
 Slow development (behavioral)

Marasmus
Inadequate calorie intake of all principle nutrients
 Body breaks down own tissues to use for energy
 Frequent infections
 Dry and baggy skin
 Sparse, dry, and brownish hair
 Decreased body temperature
 Absence of edema
 Obvious muscle wasting

Prevention and Control of PEM

 Early detection of PEM
 Underweight for age - detected by growth rate
 Waterlow's classification
 IAP Class
 Mid-arm circumference
 WHO classification

IAP Classification based on Weight

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Grading
Normal 80%+

Grade I 71-80%

Grade II 51-60%

Grade III < 50%

WHO Classification
Mean ± 2 SD

Waterlow's Classification
Height for age Normal Stunted

Weight for Height > Mean+ 2SD < m+2SD

Normal Normal Stunted (chronic)

Wasted (< m -2SD) Wasted Stunted and wasted

Degree of PEM Stunting (%) Height for age Wasting (%) Weight for height

Normal: Grade 0 >95% >90%

Mild: Grade I 87.5-95% 80-90%

Moderate: Grade II 80-87.5% 70-80%

Severe: Grade III <80% <70%

From <http://en.wikipedia.org/wiki/Malnutrition#Waterlow>

Mid-Arm Circumference
Normal > 13.5 cm

Mild to Moderate malnutrition 12.5-13.5

Severe malnutrition <12.5

Management
Domiciliary Management
 Nutritional rehabilitation at home
 For mild to moderate PEM

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Prerequisite
 Absence of severe infection
 Parental guidance
 Stress laid on locally available foods

Management in Nutritional Rehabilitation Center (NRC)

 Both hospital and domiciliary care
 2 types - day care center and residential center

Day care
 Open from 8am to 6pm daily
 Rooms for children, kitchen, teaching space

Residential Care
 Larger and more organized
 Center attached to a health center, pediatric dept. of teaching hospital
 Consists of full time in-charge person
 Supervisory staff - past time: doctor, nurse, economist, nutritionist, agriculture teacher,
extension worker

Criteria
 Children especially at risk
o Who fail to gain weight over period of 3 months
o Who cannot catch up with growth after serious illness
 Failure to breast feed
 Twins
 Mothers and children who find it difficult to cope with problem in spite of health education

Sequential Approach of Management of Severe PEM

 Treatment of Complications
o Sugar deficiency
o Hypothermia
o Infection
o Electrolyte imbalance
o Dehydration
 Begin feeding (energy dense feeding)
 Restore for height
 Catch up growth and rehabilitation
 Discharge
 Prevent relapse with follow ups

Results of Nutritional Rehabilitation

 Presumption of alertness and activity manifest as "first smile"

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 Return of appetite
 Weight gain of 10-15 kg
 Disappearance of hepatomegaly, enteropathy, and increase in serum albumin
 Transferred to home diet

Prevention of Malnutrition
Prevention at a Family Level
 Breast feeding of infants for first 6 months
 Nutritional supplementation after 6 months
 Complementary foods
 Milk, meat, eggs, or foods of increased biological value
 Adequate immunity
 Spacing between pregnancies

Prevention at a Community Level

 Early detection of malnutrition and intervention
 Nutritional education
 Vigorous promotion of family plan
 Income generation
 Promotion of education and literacy in community

Prevention at National Level

 Nutritional supplementation
 Nutritional planning

Nutritional Surveillance
 Define character and magnitude of nutritional problems
 To analyze causes of nutritional and other associated problems
 To assess government in formulating a nutritional policy
 To help government in planning, development, and implementation of projects

Nutritional Programs
 ICDs
 Mid day meal
 SNP
 WFP

Millennium Development Goals

 To eradicate extreme poverty and hunger
 To achieve universal primary education
 To promote gender equality and empower women
 To reduce child mortality
 To improve maternal health

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 To combat HIV/AIDS, malaria, and other diseases

 To ensure environmental sustainability
 To develop a global partnership for development

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Food Borne Diseases

A disease either infectious or toxic in nature, caused by agents that enter body through ingestion of
food

Classification
Due to naturally occurring toxins
 Lathyrism
 Endemic ascites

Due to toxins produced by certain bacteria

 Botulism
 Staphylococcus poisons

Due to toxins produced by fungi

 Aflatoxin
 Ergot
 Fusarium toxins

Food Borne Chemical Poisoning

 Heavy metals
 Oils, petroleum derivatives, solvents
 Migrant chemicals from package materials
 Asbestos
 Pesticide residues

Neurolathyrism
 Due to consumption of lathyrus sativus (kesari dhal)
 Toxin - Beta-oxalyl amino alanine (BOAA)
 Seeds are used to adulterate bengal gram
 Public health problem in certain parts of India (MP, Bihar, UP)
 Consumption of diet containing > 30% kesari dhal for more than 2-6 months → neurolathyrism

Stages of the Disease

 Latent stage: reversible stage
 No stick stage: walks with short jerky steps
 One stick stage: crossed gait, walks on toes, uses a stick to maintain balance
 2 stick gait: excessive bending on knees; needs 2 crutches
 Crawler stage: atrophy of thigh and leg muscles, knee joint cannot support body weight, weight
bearing on hands

Interventions
 Vit C prophylaxis

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 Banning the crop

 Removal of toxin
a. Steeping method
b. Parboiling
 Education
 Genetic approach (parboiling)
 Socioeconomic changes

Endemic Ascites
 Due to contamination of millet panicium miliase with weed seeds of crota
 Chemical: pyrolixidine alkaloids
 Hepatotoxins: ascites and jaundice
Prevention measures
 Education about
o the disease
o De-weeding of the Crotalaria plant
o Sieving at household level

Aflatoxins
Mycotoxin produced by fungi (A. Flavus and A. Parasiticus)
Fungi infest food grains
Moisture and temperature
Carcinogenic: Hepatotoxins produced

Prevention and Control

Ensure proper storage after drying
Moisture < 10%
Avoid contaminated food
Educate population

Ergot
A field fungus - Claviceps fusiformis
Infest during flowering stages
Infested seeds appear black and irregular

Symptoms
Acute: Nausea, vomiting, giddiness, etc
Chronic: painful cramps in limbs (vasoconstriction), peripheral gangrene

Prevention and control

Ergot infested grains can be easily removed by floating them in 20% salt water
By hand picking or air floatation
Upper safe limit for ergot alkaloids = 0.05 mg/100 g

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Epidemic Dropsy
Due to contamination of mustard oil with argemone oil
Toxin - sanguinarine
Interferes with oxidation of pyruvic acid
Argemone seeds resemble mustard seeds
Harvesting period is the same
Contamination - accidental or deliberate
Symptoms
Sudden bilateral swelling of legs
Dyspnea
Glaucoma
Cardiac failure
Death

Prevention and Control

Nitric acid test
Paper chromatography test
Removal argemone weeds
Enforcement of PFA (prevention of food adulteration) act

Food Additives
Adding non-nutritious substances intentionally to food

Categories
First Category
Coloring agents
Flavoring agents
Sweetness
Preservatives
Acidity imparting agents

Second Category
Contamination incidental through
Packing
Processing
Farming practices

Hazardous to health

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Food Fortification
The process
 Whereby nutrients are added to foods (in relatively small quantities)
 To maintain or improve the quality of diet of a group, cmmunity, or population

Examples
 Fluoridation of water as a measure to prevent dental caries
 Iodization of salt to prevent endemic goiter
 Foor fortification with Vit A and B
 Grain fortification

Criteria for nutrients

 Must be consumed regularly as part of the deialy diet by relavent sections of the population or
total population
 Must provide an effective supplemetn for low consumers of the nutrient, without contributin gto
an excess to high consumers
 Should not undergo any change in taste, smell, appearance, or consistency
 Price of the food product should be affordable

Food Adulteration
 Mixing
 Substitution
 Selling decomposed foods
 Misbranding
 Addition of toxicants

Disadvantages
Consumers pay more for food stuff of lower quality

May have serious effects on health

Prevention of Food Adulteration Act of 1945

Objectives
 to ensure provision of pre and wholesome food to consumers
 To protect consumers from fraudulent and deceptive trade practices

Adulteration
If proven, minimum imprisonment

Central committee for food standards

 Constituted by central government
 Implementation by state gov and local bodies
 Proper coordination

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 Monitoring
 Surveillance

Food laboratories
 Kolkata
 Ghaziabad
 Pune
 Mysore

Regular in-service training program for

 Food inspectors
 Analystis
 Senior officers concerned with implementation of the act
Food Standards
Codex Alimentaries Commision
 Formulates food standards for international market

PFA Standards
 To maintain mnimum level of qualtiy of food stuff attainable under Indian conditions
 Agmark standards
o Set by the director of marketing and inspection of gov
o Provides assurance
 ISI on any foodstuff is an assurance of good quality
 ISI and AGMARK - voluntary

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Noise Pollution
Noise: derived from the Latin word nausea
 Strong sound in wrong place at wrong time

Noise pollution: signifies the vast cacophony of sounds that are being produced in the modern life,
hazardous to health

Sources of noise: automobiles, factories, industries, aircrafts, loudspeakers, radios, TV

Properties of Noise
Loudness (intensity)
 Depends on amplitude of vibrations
 Measured in decibels
 Dangerous exposure -- max 85 db.

Frequency
 Denoted by Hz
 Human ear can hear from 20-20000 Hz

Instruments
1. Sound level meters: measures intensity
2. Octave band frequency analyzers: measure noise in octave bands
3. Audiometer - measures hearing ability

Health Impact
 Globally: 20 million people -- disabling hearing difficulties
 Developed cities: hearing impairment mostly restricted to work setting
 Developing cities: due to community sound

Effects of Noise Exposure

Auditory Effects
1. Auditory Fatigue: appears in 90 dB range; freq 400 Hz
2. Deafness
o Temporary vs. permanent
o Person generally unaware to noise around
o May result in hearing loss
 Exposure to > 160 dB --> rupture of tympanic membrane

Non auditory effects

1. Interference with speech
2. Annoyance
3. Efficiency

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4. Physiological changes - hypertension

5. Economic losses

Control of Noise
 Careful planning on cities
 Control of vehicles
 Improve acoustic insulation of buildings
 Protection of exposed persons
 Legislation
 Education

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Radiation
Sources
Natural
 Cosmic Rays
 Terrestrial atmosphere
 Internal: potassium-40 and carbon-14 isotopes

Man made
 Medical and diagnostic: x-rays and radioisotopes
 Nuclear reactors
 Nuclear fallout
 Occupational hazards

Misc.
 TV, markers, radioactive dials on watches

Types
Ionizing
 Has ability to penetrate tissues and deposited energy within them
 Present in environment
 Also produced by human

Nonionizing

Units
 Roentgen: unit of exposure (SI unit: e/kg)
 Rad: unit of absorbed dose
 Rem: product of absorbed dose and modifying factor
o Indicates degree of potential health risk
o Unit: sievert

Biological Effects
 Radiation when absorbed produces toxic free radicals
 High level exposure - substantial damage to tissues, excess = death
 Prolonged exposure - increased ill health

Somatic Effects
 Immediate radiation sickness (acute radiation syndrome)
 Delayed
o Leukemia

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o Carcinogenesis
o Fetal development abnormalities
o Shortening of life

Genetic Effects
 Chromosome / point mutation

Radiation Protection
 Radiation hygiene
 ICRP, IAEA, WHO
 ICRP recommendation
o Dose to whole population from all sources additional to natural background radiation should
not be > 5 rem over 30 years
 Radiation from outer space and background radiation = 0.1 rad/year

Steps
 Avoid unnecessary x-ray
 Adequate control and surveillance of x-ray installations, protection of workers, improvements
leading to dose reduction
 Proper use of lead shields, read rubber aprons
 Film badge (dosimeter)

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Air Pollution
The presence in the ambient atmosphere of substances generated by human activities in concentrations
that interfere with human health safety or comfort or injurious to vegetation, animals and other
environmental media

Resulting in chemicals constituting additional sources of human exposure through food or water

Sources
 Automobiles: hydrocarbons, CO, Pb, NO, particulate matter
 Industries: smoke So2, Nitrogen oxides, fly ash, hydrogen fluoride, CO2, H2S, ozone, etc
 Domestic Sources: smoke, dust, sulfur dioxide, nitrogen oxide
 Others: burning refuse, pesticides, natural sources, nuclear energy program

Temperature Inversion
 When there is rapid cooling of lower layers of air (temp inversion)
 There is little vertical motion
 Pollutants and water vapor remain trapped at lower levels --> smog

Outdoor Air Pollution

 Combustion process produces a mixture of pollutants comprising primary emissions and products
of atmospheric transformation (quinone, SO4 particles formed from combustion of sulfurous
compounds)
 Children are particularly at risk due to immaturity of respiratory organs

Indoor Air Pollution

 Indoor cooking and heating with biomass fuels (agricultural residues, dung, straw, wood) or coal
produces high levels of indoor smoke
 Exposure to indoor air pollution can lead to acute lower respiratory infection in under 5-yrs-olds
and COPD/lung cancer in adults (where coal is used)
 Acute lower respiratory infections, particularly pneumonia, continue to be the biggest killer of
young children causing more than 2milion annual deaths in developing countries
 Second highest cause of child morbidity and mortality→ diarrhea

Monitoring Air Pollution

 SO2, smoke, and suspended particles - best indicators
 Smoke index: a known volume of air is filtered through a white filter under specified conditions
and the stain is measured by photoelectric meter → smoke concentration is estimated
o Grit and dust measurement
o Coefficient of haze
o Air pollution index

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Effects of Air Pollution

Health Aspects
A major environment related health threat to children and a risk factor for acute (acute bronchitis) and
chronic respiratory infections (chronic bronchitis, lung cancer, bronchial asthma, emphysema, resp.
allergies)

Second hand tobacco smoke, certain outdoor pollutants - risk factors for cancer

Indoor air pollution from biomass fuel is one of the major contributors to the global burden of disease

Social and Economic Aspects

 Destruction of plants and animals
 Corrosion of metals
 Damage to buildings
 Cost of cleaning and maintenance
 Decreased visibility
 Soil and damage clothing

Prevention and Control

 Containment: prehension of escape of toxic substance (enclosure, ventilation, air cleaning)
 Replacement: replacing a technological process by a new one
 Dilution: establishment of green belts
 Legislation: the air Prevention and Control of Pollution Act, 1981
 International action: international network of laboratories

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Meteorological Environment
Atmospheric Pressure
Atmosphere at the earth's surface = 1 atm = 760 mmHg

Pressure decreases as altitude increases

Measurement
 Kew Pattern Station Barometer - widely used by Indian Meteorological department
 Fortin's Barometer
 Barograph - instrument for obtaining continuous record

Effects of Atmospheric Pressure on Health

High Altitude
Less dense air → decreased partial pressure of oxygen

Physiological effects
 Increased respiration
 Increased concentration of Hb
 Increased CO

Effects of sudden exposure to high altitudes

1. Acute mountain sickness: harmless, transient condition
a. Headache
b. Insomnia
c. Breathlessness
d. Nausea
e. Vomiting
f. Impaired vision
2. High altitude pulmonary edema
a. Symptoms indistinguishable from mountain sickness appears
b. Pulmonary edema → cough, irregular breathing, oligourea, mental confusion, hallucination,
stupor, seizures, coma
c. Patient should be carried to lower altitude

Effects of Exposure to Low Altitude

 Atmospheric pressure increases by 1atm for 33 feet of depth below sea level
 Man exposure
o to increased pressure → gases in air are dissolved in blood and tissues
 Excess of N, CO2, and O are deleterious to health
 When a person comes to the surface, gases dissolved in blood under pressure are released → air
embolism (Caisson disease → bends)

Heat Stress
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Heat stress is the burden of heat that must be dissipated if the body is to remain in thermal equilibrium
 Equatorial Comfort Index
 Heat Stress Index
 Predicted Four Hour Sweat Rate

Effects fo Heat stress

Heat Stroke
Attributed to failsure of heat regulating mechanism
 Increased body temp (can cross 110F)
 Delirium, convulsions, loss of consciousness
 Skin dry and hot
 Often fatal

Heat hyperpyrexia

Heat exhaustion
Inadequate replacement of water and salts

Heat cramps
Loss of NaCl in the blood

Heat Syncope

Prevention Measures of Heat Stress

 Replacement of water
 Regulation of work
 Clothing
 Protective devices
 Work environment

Effects of Cold Stress

General Cold injury (Hypothermia)
Numbness, loss of sensation, muscular weakness, desire for sleep, coma, death

Local Cold Injury

 Immersion or trench foot (at temp above freezing)
 Frostbite (at temp below freezing)

Humidity (Moisture)
Absolute humidity: weight of water

Relative humidity: % of moisture present in air, complete saturation being taken as 100%

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Water
Improved water drinking source
An improved drinking water source is one that by nature of its construction adequately protects the
source from outside contamination, in particular from fecal matter

Reasonable access: 20L/person/day from a source within 1km of user's dwelling

Water Related Diseases

Biological (Water borne diseases)
Due to presence of infecting agent
 Viral Hep A and E, poliomyelitis, rotavirus, diarrhea
 Bacterial typhoid, cholera, bacillary dysentery, E. Coli diarrhea
 Protozoal: amebiasis, giardiasis
 Helminthic: round worm, hydatid disease
 Leptospiral: Well's disease

Due to presence of an aquatic host

 Snail: schistosomiasis
 Cyclops: guinea worm, fish tape worm
o Guinea worm → dracanculeasis (but now eliminated)

Chemical
Possible long term effects of low level exposure to chemical constituents (detergent solvents,
cyanides, heavy metals, minerals, organic acids, dyes, ammonia, organic compounds)

Others
 Diseases transmitted due to inadequate use of water
o Shigellosis, trachoma, conjunctivitis, ascariasis, scabies
 Diseases related to disease carrying insects breeding in or near water
o Malaria, filaria, arbovirus

Safe and Wholesome Water

 Free from pathogens, harmful chemicals
 Plesant to taste (tasteless, odorless)
 Usable for domestic purposes

Requirements
Basic physiological requirements: 2L/person/day

150-200L/capita adequate for everything

Sources of Water Supply

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 Rain water
 Surface water
o Impounding resevoirs
o Rivers and streams
o Tank, ponds, lakes
 Ground water
o Shallow wells
o Deep wells
o Springs

Sanitary Well
Well which is properly located and protected against contamination

Location
 Not less than 15m from likely sources of contamination
 No user will have to carry water fro > 100 m

Lining
 Built

(continue this section from the book)

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Water Purification
Purification of Water on a Large Scale
Storage of water: Natural or Artificial Reservoirs
1. Physical changes: 90% of suspended impurities settle down
2. Chemical changes: oxidation of organic matter
3. Biological changes: bacterial count drops by 90% in 5-7 days

Filtration
98-99% of bacteria, other impurities

Types of Filters
 Slow sand or biological filter
 Rapid sand or mechanical

Elements of Slow Sand Filter

 Supernatant (raw) water
 A bed of graded sand (supporting gravel)
 An under-draining system
 A system of filter control valves

Slow Sand Filter

1. Supernatant water:
a. Provides constant head of water
b. Provides waiting period of 3-12 hours
2. Sand Bed
a. Most important part
b. 1 meter in thickness
c. 0.2-0.3 mm effective diameter
d. Straining, sedimentation, absorption, oxidation, bacterial activity
Vital Layer
1. Schmutzdecke, zoogleal layer, biological layer
2. Slimy growth covering sand bed
3. Consists algae, plankton, diatoms, bacteria
4. Formation - known as ripening of filter
5. Heart of slow sand filter
6. Removes organic matter, holds back bacteria, oxidizes ammonia nitrogen

Under Drainage system

 Consists of perforated pipes
 Provides outlet for filtered water
 Supports filter medium above

Filter Box

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 Contains supernatant water, sand bed, and underdrainage system

 2.4-4 meters
 Walls of stone, brick, or cement

Filter control
 Valves and devices incorporated in outlet pipe system
 Volume meter measure bed resistance or loss of head

Cleaning of filter
 Supernatant water drained off top layer of sand scraped off

Advantages
 Simple to construct and operate
 Cheap
 Quality of filtered water is very high

Rapid Sand or Mechanical filters

1. Gravity type (Paterson's filter)
2. Pressure type (candy's filter)

Steps involved
 Coagulation: water treated with alum
 Rapid mixing: violent agitation in mixing chamber
 Flocculation: slow and gentle stirring in flocculation chamber for about 30 min
 Sedimentation: coagulation water detained for 2-6 hours; flocculent particulates settle down

Filter beds
 Sand is filtering medium (effective size 0.4-0.7mm)
 Depth of sand bed is 1 meter
 Gravel supports the sand bed
 Under-drains collect filtered water

Filtration
 Alum flow held back on sand bed
 Forms slimy layer
 Absorbs bacteria from water
 Oxidation of ammonia

Backwashing
 Washing accomplished by serving flow of water through sand bed

Advantages
 Can deal with raw water directly
 Filter beds occupy less space
 Rapid filtration (AD 50x slow sand filter)

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 Washing the filter is easy

 More flexibility in operation

Disinfection
Chlorination
 Chlorine kills pathogenic bacteria
 No effect on spores, certain viruses (polio, viral hepatitis) protozoal cyst, helminthic ova
 Oxidizes Fe, Mn, H2S
 Controls algae and other organisms
 Acid coagulation

Actions of chlorine
H2S + Cl → HCl + HOCl

HOCl → H+ + Ocl

Disinfection action of chlorine

 Mainly due to hypochlorous acid
 Small extent due to hypochlorite ion

Acts best in the pH of water = 7

Principles of chlorination
 Water to be chlorinated should be clear
 Chlorine demand of water estimated (difference between amount of chlorine added to water and
amount of residual chlorine remaining at end of 60 min, at a given temp and pH of water)
 Point at which chlorine demand of water is met: "break point"
 If further Cl2 is added, free chlorine appears (HOCl and OCl)
 Presence of free residual chlorine for a contact period of at least the time essential to kill bacteria
and viruses
 Minimum recommended concentration of free chlorine is 0.5 mg/L for one hour
 Sum of chlorine demand plus free residual Cl of 0.5 mg/L constitutes the correct dose of Cl to be
applied

Method of Chlorination
1. Chlorine gas
a. First choice: cheap, quick, effective, easy to apply
b. Chlorinating equipment is required - Patterson's chloro)
2. Chloramine
3. Perchloron

Superchlorination
 Addition of large doses of chlorine to water and removal of excess of chlorine after disinfection
(dechlorination) is applicable to highly polluted water

Orthotolidine (OT) test:

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 Enables free and combined Cl in water to be determined

 OT determines free and combined Cl residuals separately

Other agents
1. Oxonation
a. Powerful oxidizing agent
b. Strong virucidal effect
c. No germicidal effect
d. Commonly employed (0.2-1.5 mg/L) in combination with chlorination
2. Ultraviolet irradiation

Purification of Water on a Small Scale

Household purification of water
1. Boiling
2. Chemical disinfection
a. Bleaching powder (chlorinated lime - CaOCl2)
b. Chlorine solution
c. High test hypochlorite
d. Chlorine tablets
e. Iodine
f. Potassium permanganate
3. Filtration - ceramic filters
a. Pasteur chorabesland filter
b. Berkenfeld filter
c. Katedyn filter

Usually removes bacteria but not passing viruses

Disinfection of walls
 Most effective and cheapest mosthod of disinfecting wells - bleaching powder
 Chlonine demand of well water is stimated by using Horrock's apparatus

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Waste Disposal
Solid Waste (Refuse)
Garbage
 Rubbish
 Demolition products
 Sewage treatment residue
 Dead animal, plants

Health Hazard
 Favors fly breeding
 Attracts rodents, vermin
 Pathogens conveyed back to flood
 Water and soil pollution
 Unsightly appearance; bad odors

Methods of disposal
Dumping
 In low lying area
 Most insanitary methods
Controlled tipping (sanitary landfill)
 Most satisfactory where suitable land
 Material adequate compacted covered with earth

Methods:
 Trench method: where ground level available
 Ramp method: terrain is moderately sloping
 Area method for filling land depressions, disused quarries and clay pits

 Chemical, bacteriological, physical changes

 Temp increases > 60C in 7 days - kills pathogens
 4-6 months - complete decomposition

Incineration
 No suitable land available
 Hospital waste

Compost pit
 Combined disposal of refuse and night soil or sludge
 Organic matter breaks down - bacterial action - forming compost
 Compost: few or no disease producing organism, manure

Manure
 Bangalore method (anaerobic)

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 Mechanical method (aerobic)

Burial

Excreta Disposal
Sanitation Barrier
Sanitary latrine and a disposal pit or a sewage system and sewage treatment plant provide a barrier
which segregates excreta so that disease agent cannot reach new host either directly or indirectly
through various channels

Septic Tank
A water tight masonry tank into which household sewage

Working
 Solid settles down "sludge"
 Lighter solids, grease, fats rise to surface: "scum"

Stages of Purification
Anaerobic digestion
 In septic tank
 Sludge, much decreased in volume, rendered stable, inoffensive
Aerobic oxidation
 Outside in subsoil
 Liquid passing out: "effluent"
 Numerous bacterial, cysts, helminthic ova, organic matter
 Effluent percolates into subsoil by means of perforated pipes in trenches - 3 feet deep,
covered with soil

Operation and Maintenance

 Use of soap, disinfectants avoided
 De-sludging
Sewage and Sullage
 Waste water

Dry weather flow: sewage through sewage system in 24 hours

Biochemical Oxygen Demand

 Most important test on sewage - expresses 'strength' of sewage
 Amount of oxygen absorbed by sample of sewage during specified period at specific tempt
(generally 20C) for aerobic

Modern sewage treatment - 2 stages

Primary treatment
 Solids separated

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 Anaerobic digestion

 Screening
 Grit chamber
 Primary sedimentation
a. Large tank
b. Sewage flows very slowly
c. 50-70% solids settle
d. 30-60% decrease in coliform organism
e. Organic matter: sludge
 Secondary enatment
a. Aerobic oxidation - trickling filter method
b. Activated sludge process

Trickling filter (percolating filter)

o Bed of crushed stones
o Effluent sprinkled uniformly - surface revolving devices
o Biological growth (zoogleal layer)

Activated sludge process

o Modern method
o Aeration tank: "Heart of the process"
o Effluent primary mix: sludge drawn from final settling tank (act sludge or return sludge)
o Mixture sub

 Secondary sed:
a. Oxidation sewage into sedentary sedimentation tank: 2-3 hours
b. "activated sludge" (after aerated)
c. Partly pump
 Digestion
a. Disposal digestion: anaerobes auto digestion
b. Sea disposal
c. Compacting
 Disposal of effluent
a. By dilution into water courses
b. On land

Secondary treatment
 Aerobic oxidation

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